Vacation Bible School Registration
Dates: June 1–5 Time: 6:00 PM – 8:30 PM Location: Selma Baptist Church
Child’s Full Name
*
First Name
Last Name
Age and Date of Birth
*
Grade Completed
*
Parent/Guardian Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Emergency Contact Name & Phone
*
Allergies / Medical Information
*
Pickup Authorization
*
Church Home
Submit
Should be Empty: