2026 VBS Registration Form

2026 VBS Registration Form

Immanuel Lutheran Church: 3834 Rockingham Road, Davenport, Ia 52802 (563) 324-6431
Parent/Guardian Full Name*

First NameLast Name
Relationship to Student*
Parent/Guardian Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Other Phone Number
Please enter a valid phone number.
Emergency Contact Name (if different from above)

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Alternate Pickup Name

First NameLast Name
Alternate Pickup Phone Number
Please enter a valid phone number.
Student Full Name*

First NameLast Name
Student Nickname
Student Age*
Grade in Fall 2026*
Gender*

MaleFemaleOther
Allergies (if any)
Special Needs (if any)
Student Address and Phone (if different from parent/guardian)
Signature of Parent/Guardian*

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Date*

MonthDayYear
Date
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