Please enable JavaScript in your browser to complete this form.Parent/Guardian Name *FirstLastAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMailing Address Same As Billing Address? *YesNoMailing AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeContact Information Cell *HomeWorkEmail *Child's InformationHow Many Children Are You RegisteringOneTwoThreeFourFiveChild's Name *FirstLastChild's Birth Date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Last Grade Completed In School *Select GradeKindergarden1st Grade2nd Grade3rd Grade4th Grade5th Grade6th GradeT-Shirt Size *Youth XSYouth SYouth MYouth LAdult SAdult MSecond ChildChild Two Name *FirstLastChild Two Birth Date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child Two Last Grade Completed In School *Select GradeKindergarden1st Grade2nd Grade3rd Grade4th Grade5th Grade6th GradeChild Two T-Shirt Size *Youth XSYouth SYouth MYouth LAdult SAdult M (copy) Child Name Third ChildChild Three Name *FirstLastChild Three Birth Date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child Three Last Grade Completed In School *Select GradeKindergarden1st Grade2nd Grade3rd Grade4th Grade5th Grade6th GradeChild Three T-Shirt Size *Youth XSYouth SYouth MYouth LAdult SAdult MFourth ChildChild Four Name *FirstLastChild Four Birth Date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child Four Last Grade Completed In School *Select GradeKindergarden1st Grade2nd Grade3rd Grade4th Grade5th Grade6th GradeChild Four T-Shirt Size *Youth XSYouth SYouth MYouth LAdult SAdult MFifth ChildChild Five Name *FirstLastChild Five Birth Date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child Five Last Grade Completed In School *Select GradeKindergarden1st Grade2nd Grade3rd Grade4th Grade5th Grade6th GradeChild Five T-Shirt Size *Youth XSYouth SYouth MYouth LAdult SAdult MMedical InformationMedical or other information we need to know. (Please include any food allergies)Dismissal Information Who may pick up your child at the end of each VBS day? Name *FirstLastName (copy)FirstLastName (copy) (copy)FirstLastOther InformationDoes Your Child Attend Church? If So, Where? *YesNoChurch NameIf Your Child Is Visiting Our Church, Who Is He/She A Guest Of?May We Have Permission To Photograph Your Child? *YesNoMay We Have Permission To Use Your Child's Photograph For The Purpose Of Promotion?YesNoSubmit
