Shiloh VBS 2025

STUDENT INFORMATION

Last Name*

First Name*

M.I.

Date of Birth*

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Grade completed by May 2025*

4th grade

Gender

YesNo

If yes, what year?

Home Church (if any)

Street Address*

Street Address Line 2*

City*

Postal Code*

Primary Phone Number*

Secondary Phone Number

EMERGENCY CONTACTS
Please list the first and last names and phone numbers off 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*

Format: (000) 000-0000.

Alternate Guardian #1*

First NameLast Name

Relationship to child and phone number of Alternate Guardian*

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

Please list the names of any other children (friends or family) that you would like placed in the same class as this child

YesNo

By submitting this form, I ackowledge I have read and understand the above information.