Last Initial: _______ 

Group:________________

2010 VBS Registration Form

Child’s Name__________________________________________________________

Child’s Age ____ Date of Birth ___________ Last School Grade Completed _______

Allergies or other Medical Information_______________________________________

_____________________________________________________________________

Mailing Address: _______________________________________________________

City____________________________ State___________ Zip__________________

Parent/Guardian Name(s): _______________________________________________

Home Phone:_____________ Work:__________________ Cell:_________________

Email Address: ________________________________________________________

Emergency Contact: Name_______________________ Phone________________

Who may pick up your child from VBS each day?______________________________

May we have permission to photograph your child and use photos for presentations,

advertising or contests?  YES     NO

Home Church__________________________________________________________

Name of a friend your child may like to be with ________________________________

http:www.salembaptist.org

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