EmailMe Form - VBS 2016 Surf Shack Registration Form

Child's Name *
First Last
Male of Female *
Male
Female
Parent/Guardian Name *
First Last
Email *
Address *

Street Address City State / Province / Region Postal / Zip Code
Home Phone *
### - ### - ####
Cell Phone *
### - ### - ####
Work or Other Phone
### - ### - ####
Age of Child *
Date of Birth *
Last school grade completed
Allergies/Medical Information/Other *
Rising Grade
Emergency Contact 1 *
First Last
Phone *
### - ### - ####
Name/Relationship to Child *
Emergency Contact 2
First Last
Phone *
### - ### - ####
Name/Relationship to Child *
Please check if we can use your child pictures on slideshow, facebook, church website.
YES
NO