Child's First Name	Child's Last Name	Gender      Male Female
Date of Birth (YYYY-MM-DD)	Phone

           

Street Address

State

City

Zip Code

 Name of one friend with whom you would like your child grouped
 

Please select one VBS group for your child  Grade        1st 2nd 3rd 4th 5th  Grades 1-5, which grade did your child complete in May 2008?   OR  Big Dippers  My child was in Kindergarten this year (2007-2008) My child will attend Kindergarten this fall (2008)  OR   Little Dippers I (the parent) am working in the VBS program, thus allowing my preschool children to attend.

Parent/Guardian's Name

Phone Number (in case of an emergency)

Email (if supplied, a VBS Registration confirmation email will be sent to you)

Any special needs, allergies, etc.

Special Care Instructions

Do we have your permission to use a picture of your child at VBS on our website (no names)?      Yes No