Shipwrecked- VBS Registration
Please submit one for each child
Child's Name
*
First Name
Last Name
Child's Gender
Male
Female
Prefer not to answer
Child's Age
*
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Last school Grade Completed
*
Pre-School
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Phone Number
*
-
Area Code
Phone Number
Contact E-mail
Child's Home Church
Any Additional Info
Emergency Contact / Medical Information
Allergies or Other Medical Conditions
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Number
*
-
Area Code
Phone Number
Relationship to Child
Register
Should be Empty: