VBS Registration – 2017

May 8th, 2017

Name of Child (required)

Grade this Fall (required)

Child's Birthday (required)

Your Name (required)

Your Email (required)

Your Street Address (required)

Your City, State, Zip

Your Phone - Mom

Your Phone - Dad

Your Home Church (if not Salem)

IN CASE OF EMERGENCY, CONTACT:

Name (required)

Relationship (required)

Phone number(s) (required)

If the person listed above cannot be reached, please call:

Name

Phone number(s)

MEDICAL INFORMATION

Are there any special diets, allergies, medications, restrictions of activities, or behavior issues we need to be aware of?

PERMISSION

  • Doctor:
  • Doctor's Phone:
  • Medical Insurance Carrier:
  • Medical Insurance Policy #:

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