Vacation Bible School Registration

**Registration is now closed for VBS. Please contact Emily Lieske at emily_lieske@hotmail.com if you have any questions.
Child's Name:*

First NameLast Name
Birth Date:*

MonthDayYear
Grade Completed:*

Parent/Gardian:*

First NameLast Name
Home Phone:*

Area CodePhone Number
Cell Phone:

Area CodePhone Number
E-mail:*

Emergency Contact:*

First NameLast Name
Emergency Contact Phone:*

Area CodePhone Number
Who is Picking up Child:

Should be Empty: