EmailMe Form - Vacation Bible Study "Gadgets & Gizmos "

Child's Name *
First Last
Age *
Date of Birth
MM / DD / YYYY
Grade Completed *
Age 3
Age 4
Age 5
Age 6
1st Grade - completed
2nd Grade - completed
3rd Grade - completed
4th Grade - completed
5th Grade - completed
6th Grade - completed
Parent/Guardian Name *
First Last
Phone *
### - ### - ####
Email
Number List *

Painting

Pottery

Art

Dance

vocal music

Guitar

Piano

Drama

Photography

Drawing

Quilting

God rods
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Emergency Contact
First Last
Emergency Contact Phone
### - ### - ####
Special Needs/Allergies/Other Concerns
Person(s) to whom child may be released:
Siblings Attending? Please include their names and ages.
Permission to use pictures in church publications: *
Yes
No
Church Affiliation
Would parent like to participate in VBS?
Yes
No
Number List

Number 1

Number 2

Number 1
Number 2