1776 The Town Square
Salem MB Church June 28-July 2 6:30pm-8:30pm
Parent's Name
First Name
Last Name
Email
example@example.com
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number (His)
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number (Her)
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Aress Line 2
City
State / Province
Postal / Zip Code
Church Attending
School Attending
Emergency Contact Person
Emergency Contact Person’s Phone
Child Name
First Name
Last Name
Age
Gender
Male
Female
Grade Entering
Child’s Allergies
Child Name
First Name
Last Name
Age
Gender
Male
Female
Child’s Allergies
Grade Entering
Child Name
First Name
Last Name
Age
Gender
Male
Female
Grade Entering
Child’s Allergies
Child Name
First Name
Last Name
Age
Gender
Male
Female
Grade Entering
Child’s Allergies
Do you allow release of photographs of your child(ren) for publication?
*
Yes
No
If your child is 4 years old, and attending his/her first year of VBS, is he or she potty-trained?
Yes
No
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