VBS Registration
Valley Community Chapel
DATES: July 7-11
TIME: 9am - Noon
AGES: 3-12
Preschool is FULL
Child Information
Child Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Last Grade Completed
*
Kindergarten
1st
2nd
3rd
4th
5th
6th
Child 2 (Click to add another child)
Child Name
First Name
Last Name
Birthday
-
Month
-
Day
Year
Date
Last Grade Completed
Kindergarten
1st
2nd
3rd
4th
5th
6th
Child 3 (Click to add another child)
Child Name
First Name
Last Name
Birthday
-
Month
-
Day
Year
Date
Last Grade Completed
Kindergarten
1st
2nd
3rd
4th
5th
6th
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Parent Information
Parent Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Emergency Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship to Child
Medical Information
Allergies or Other Medical Conditions
Additional Information
Is there another child attending that you would like your child to be placed with?
Your Home Church
Media Release: Does VCC have permission to use photos or videos with your child for media purposes?
Yes
No
Submit
Should be Empty: