Form

Rock Springs United Methodist Church
Vacation Bible School
Registration

Complete one form for each child attending...thank-you
Child Name *

First Name Last Name
Birth Date *

Month Day Year
Age *
Last Grade *
Home Church:
Allergies, Medications and instructions:
Parent / Guardian Information
Parent/Guardian *

First Name Last Name
Street Address *
Phone Number *

- Area Code Phone Number
Cell Phone: *

- Area Code Phone Number
E-mail *
Emergency Contact:

Name Phone
Emergency Contact:

Name Phone
Emergency Contact:

Name Phone
Name of person who may pick up this child from VBS:
Is there any other information we should know while caring for this child today ?
Should be Empty:

Rock Springs United Methodist Church