FBC Kountze - VBS Registration Form
June 26-30, 8:45 AM - Noon
Student's Name:
*
First Name
Last Name
Boy or Girl
*
Boy
Girl
Birth Date:
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
Year
Age:
*
Classes for Kinder - 6th Grade
Must have completed assigned grade: NO EXCEPTIONS
Class Assigned
*
Kinder - 1st
2nd - 3rd
4th - 6th
Parent/Guardian:
*
First Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Primary Phone:
*
Secondary Phone:
E-mail:
Emergency Contact:
First Name
Last Name
Emergency Contact Phone:
Siblings Attending:
Relatives/Friends Authorized to Pick-up Child
Special Needs / Allergies / Concerns:
Children with special needs may require you to provide a care taker
Submit
Should be Empty: