Child's name:               

Parent/Guardian Name:  

Address: 

Phone Numbers:  

Home:           Work:           Cell:           

Email:  

Age Information:   
Birth Date:                      Grade entering this Fall:   Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade

Medical Information:   Medical or other information we need to know.   Please include food allergies.

Name:              Phone Number:  

Name:            Phone Number:  

Dismissal Information:          Who may pick up your child at the end of VBS each day?

 Other Information:

 Do you attend a church?  If so, where?   

How did you find out about VBS?     Flier Newspaper Guest of: Other:

May we have permission to photograph your child?     Yes    No

May we have permission to use your child’s photograph in church publications for the purpose of promotion?    Yes    No

May we have permission to use your child’s photograph on the Prairie Springs Church website for the purpose of promotion?     Yes    No