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VBS 2012 Registration
The Scottish Sleuths and The Case of the Hidden Hero
July 16-20
9am-12pm
Parents Information
Parent/Guardian #1
First
Last
Phone
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Parent/Guardian #2
First
Last
Phone
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Address
Address (Line 2)
City
State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP Code
Email
Home Church
In Case of Emergency Please contact:
Name
First
Last
Phone
###
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Other adults authorized to pick up my child
Child #1 Information
Name
First
Last
Gender
Male
Female
Age of child as of July 16
Birthdate
MM
/
DD
/
YYYY
Last Grade Completed
or Preschool Class
Any known allergies
Current Medications
If possible place my child with:
Sibling #2 Information
Name
First
Last
Gender
Male
Female
Age of child as of July 16
Birthdate
MM
/
DD
/
YYYY
Last Grade Completed
or Preschool Class
Any known allergies
Current Medications
If possible place my child with:
Sibling #3 Information
Name
First
Last
Gender
Male
Female
Age of child as of July 16
Birthdate
MM
/
DD
/
YYYY
Last Grade Completed
or Preschool Class
Any known allergies
Current Medications
If possible place my child with:
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