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VBS REGISTRATION FORM (one per child) completed K - Grade 6

Child's Name*

Child's Gender

Child's Age

Date of Birth

Last School Grade Completed

Name of Parents (s)

Street Address

City, State, Zip

Home Telephone

Parent/Caregiver's Cellphone

Home Email Address

Home Church

Allergies, Medical Conditions, or Special Needs

In Case of Emergency, Contact Name(s)

Phone of Emergency Contact(s)

Relationship to Child

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