VBS 2023 Registration Form

Concordia Lutheran Church

Vacation Bible School 2023

Student Registration Form

VBS Logo

VBS 2023 Dates: Sunday July 16th - Thursday July 20th from 5:15pm - 8:00pm

Location: Concordia Lutheran Church

185 Concordia Church Rd

China Grove, NC 28023

Institution Name

STUDENT INFORMATION

Last Name*

First Name*

M.I.

Birth Date *

MonthDayYear

Gender

Grade Level completed by June 2023*

YesNo

Home Church (if any)

Street Address*

Street Address Line 2

City*

Postal Code*

Primary Phone Number*

Secondary Phone Number

Siblings Enrolled in VBS 2023

First NameLast Name

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*

Area CodePhone Number

Alternate Guardian #1*

First NameLast Name

Relationship to child*

Phone Number*

Area CodePhone Number

Alternate Guardian #2

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

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

YesNo