St John Lutheran Church
VBS 2010 Registration for Preschool - 5th Grade
First Name:
*
Last Name:
*
Phone Number:
*
Cell Number:
E-mail Address:
*
Street Address:
*
Address Line 2:
City:
*
State:
*
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
-Terr.-
AS
FM
GU
MI
PR
VI
Postal Code:
*
Email Address
*
Child #1 Name
Child #1 Grade Level
Child #2 Name
Child #2 Grade Level
Child #3 Name
Child #3 Grade Level
Emergency Contact & Phone
Allergies or medical conditions?
Doctor Name & Phone Number
People allowed to pick up your children
I hereby grant the VBS leaders at St John Lutheran Church permission to photograph the minor here designated in any manner or form for any lawful purpose associated with this VBS program.
Questions?
*
Required
Create Email Forms
VBS Schedule: June 13 - 17, 2010
5 PM: Dinner at St. John
6 - 9 PM: VBS Classes
