VBS Registration

VBS Registration Form

One Per Child
Zion Lutheran Church

4447 Central Ave

Gasport, NY 14067

August 11th - August 15th, 2025

9:00 am - 12 Noon

Cost: Free

Questions: Contact Kim or Melissa

Email: zionlutherangasportvbs@gmail.com Call/Text: 716.266.2982
Child's Information
Child's Name*

Child's First NameChild's Last Name
FemaleMaleChoose not to disclose
Child's Age*
ex. 5 years
Child's Birthdate*

MonthDayYear
Date
Last School Grade Finished*
ex. 6th Grade
Parent/Guardian Information
Name of Parent/Guardian 1*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Parent/Guardian 2

First NameLast Name
Home Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Caregiver's Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Email Address
example@example.com
Home Church
ex. Zion Lutheran Church
Medical and Emergency Information
Allergies, Medical Conditions, or Special Needs*
If not applicable, please type N/A
In Case of Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child*
Miscellaneous
Monday, August 11, 2025Tuesday, August 12, 2025Wednesday, August 13, 2025Thursday, August 14, 2025Friday, August 15, 2025
YesNo
Should be Empty:

VBS Registration Form