VBS Registration - Elim Lutheran Church

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Name of Participant #1 *

First

Last

Date of Birth *

Grade Entering *

Participant #2 (If Applicable) *

First

Last

Date of Birth *

Grade Entering *

Participant #3 (If Applicable) *

First

Last

Date of Birth *

Grade Entering *

Participant #4 (If Applicable) *

First

Last

Date of Birth *

Grade Entering *

Participant #5 (If Applicable) *

First

Last

Date of Birth *

Grade Entering *

Parent/Guardian *

Emergency Contact *

Home Phone *

Cell Phone *

Emergency Number *

Person(s) picking up attendee *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Special Needs / Medical Concerns *

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