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VBS Registration Form
Illumination Station VBS
June 21-26 • 6:00-8:30 PM
Child's Name *
Parent/Guardian Name *
Physical Address *
Mailing Address, if different
Home Phone
Cell Phone *
Email *
Birth Date *
Last Grade Completed *
Medical Information / Food Allergies
Emergency Contacts, other than listed above *
Who may pick up your child at the end of VBS? *
Any other information?
May we have permission to photograph your child? *
Please select
Yes
No
May we use your child's photograph for promotion? *
Please select
Yes
No
Leave this field blank
Security Question: What is 9 + 3? *
Submit Registration