Community VBS Registration Form
Please fill out this form to register your child for the VBS program.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Grade Completed
*
Please Select
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
List any allergies, medical conditions, or special needs
Who is authorized to pick up your child?
Register
Should be Empty: