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2010 Child VBS Registration Form
(one child per registration)
Child's Information  
First Name
Middle
Last Name
Age
Gender Male  Female
Last School Grade Completed
Allergies/Medical Information
Parent/Guardian's Information  
First Name
Middle
Last Name
Address
City, State ZIP ,   
E-mail Address
Home Phone
Cell Phone
Work Phone
Emergency Contacts
Name(s) of person(s) in addition to the parent/guardian who can be contacted in case of emergency.
First Contact Name
Phone
   
Second Contact Name
Phone
Dismissal Information
Name(s) of person(s) who may pick up this child from VBS.
Name
Name
Name
Name