EmailMe Form - Lakewood Chapel VBS Sign-Up

Child's Name *

First Last

Child's Gender *

Child's Age *

Date of Birth *

MM / DD / YYYY

Last School Grade Completed *

As of July 2026

Parent Name *

First Last

Other Parent's Name

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Parent/Guardian Cell Phone *

### - ### - ####

Parent/Guardian Home Phone

### - ### - ####

Parent/Guardian Email Address *

Home Church

Allergies or other medical conditions

In case parents are unavailable, emergency contact name *

First Last

Emergency contact phone *

### - ### - ####

Relationship to child *