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July 12th - 16th (6:30 pm - 9:15 pm)
Contact Information
Child's Name
Parent's Name
Street Address 1
Street Address 2
City
State
Alabama
Alaska
American Samoa
Arizona
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Colorado
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District Of Columbia
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Texas
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Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
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Zip Code
Phone Numbers
Home:
Work Phone
Cell Phone
Email Address
Age Information
(Ages 4 through 5th Grade)
Birth Date
Last Grade completed in School
4 years old
Pre School
Kindergarden
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
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)