CCC VBS Registration 2024

CCC VBS Registration 2024

STUDENT INFORMATION: for 4yrs through entering 6th Grade
Last Name*
First Name*
M.I.
Birth Date *

MonthDayYear
Grade entering Fall 2024*
Home Church (if any)
Home Street Address*
Street Address Line 2*
City*
Postal Code*
Primary Phone Number*
Primary email address
EMERGENCY CONTACTS: Please list the first and last names and phone numbers of ALL adults who are allowed to pick up this child. The child will only be released to these people.
Primary Guardian*

First NameLast Name
Relationship to child*
Phone Number*

Area CodePhone Number
Alternate Guardian #1*

First NameLast Name
Relationship to child*
Phone Number*

Area CodePhone Number
Medical Information
Please list all allergies -- or type "none" if there are none*
YesNO
Please list all medical concerns -- or type "none" if there are none*
Additional Information
YesNo