July 12th - 16th (6:30 pm - 9:15 pm)
Contact Information
Child's Name
Parent's Name
Street Address 1
Street Address 2
City
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Phone Numbers Home: Work Phone Cell Phone
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Age Information (Ages 4 through 5th Grade)
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Medical Information
Medical or other information we need to know. (Please include any food allergies)
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Emergency Contact Name: Phone Number Name: Phone Number
Dismissal Information
Who may pick up your child at the end of each VBS day?
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Permission
May we have permission to photograph your child? (check box for yes)
May we have permission to use your child's photograph in church publications for the purpose of promotion? (check box for yes)

11093 Alexandria Pike • Alexandria, KY  41001
Phone: 859-474-3100 • Fax: 859-474-3093 • info@sievechurch.org
© 2010 Main Street Baptist Church • Design licensed under a Creative Commons Attribution 2.5 License
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