Immanuel's VBS Registration Form

Immanuel's VBS Registration Form

Immanuel's VBS Registration Form

July 14-17, 9:00 am to 12:00 pm; for children ages 4 years old (by 1-1-2025) through 5th Grade
Child's Name

First NameLast Name
Birth Date

MonthDayYear
Last Grade Completed
Home Phone Number
Format: (000) 000-0000.
Mobile Number
Format: (000) 000-0000.
Email Address
example@example.com
Desired Name Tag
Primary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please provide any medical or dietary restrictions you have

Family Information
Parent/Guardian's Name

First NameLast Name
E-mail Address
example@example.com
Contact Phone Number
Format: (000) 000-0000.
Emergency Contact Information
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Format: (000) 000-0000.
Relationship to Student

2nd Child's Name

First NameLast Name
Birth Date

MonthDayYear
Last Grade Completed
Please provide any medical or dietary restrictions you have
3rd Child's Name

First NameLast Name
Birth Date

MonthDayYear
Last Grade Completed
Please provide any medical or dietary restrictions you have
4th Child's Name

First NameLast Name
Birth Date

MonthDayYear
Last Grade Completed
Please provide any medical or dietary restrictions you have
Should be Empty: