Vacation Bible School Registration Form

Child Information

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* 1. Name:

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* 2. Date of birth:

Date / Time

Date

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* 3. Last grade completed:

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* 4. Home address:

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* 5. Church affiliation:

Member

Guest

Parent/Guardian 1 Contact Information

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* 6. Name:

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* 7. Email:

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* 8. Cell phone number:

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* 9. Work phone number:

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* 10. Address:

Parent/Guardian 2 Contact Information

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* 11. Name:

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* 12. Email:

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* 13. Cell phone number:

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* 14. Work phone number:

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* 15. Address:

Emergency Contact

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* 16. Name:

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* 17. Relationship to child:

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* 18. Email:

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* 19. Cell phone number:

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* 20. Work phone number:

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* 21. Address:

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* 22. Names of other people authorized to pick child up:

Medical Information

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* 23. Primary care doctor:

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* 24. Email:

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* 25. Phone:

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* 26. Address:

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* 27. Insurance provider:

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* 28. Insurance plan number:

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* 29. Allergies:

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* 30. Other important medical information: