VBS Registration

Participant #1

Participant Name

*

Age

*

Grade

*

List all known allergies

*

Participant #2

Participant Name

Age

Grade

List all known allergies

Participant #3

Participant Name

Age

Grade

List all known allergies

Parent/Guardian Information

Parent/Guardian Name

*

Email

*

This address will receive a confirmation email

Phone

*

Address

*

Relationship

*

I give consent for my child(ren)s image to be published online and in print

*

Yes No

Payment

Suggested Donation (to help offset costs of supplies and dinner)

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

June 5th-8th (5:00 - 7:30 PM)

For kids ages 4 yrs - 5th grade

Please use this form for up to three (3) children. A separate registration
form must be used for additional participants.