Galactic Blast V.B.S. Registration

Child's Name*

School grade in the fall*

Date of birth

Child's address

Parent's/Guardian's name*

E-mail Address

Home telephone number

Cell phone number

Home church

City, State, Zip

Allergies/Medical/Other

First emergency contact name

First emergency contact telephone

Second emergency contact name

Second emergency contact telephone

Dismissal Information, Name(s) of person(s) who may pick up this child from VBS