Please complete all fields:  

Family Last Name    

Children enrolling in VBS  - ages 4 years old through 6th grade

 # 1 First Name:      # 1 Grade (Fall 2010)  

 # 2 First Name      # 2 Grade (Fall 2010)

 # 3 First Name:    # 3 Grade (Fall 2010)

  Address   

  City:              State:     ZIP: 

  Home phone                 Alt. phone

  Parents’ Names    

  Church Currently Attending:

  E-Mail address      

  How did you hear about VBS? (Check all that apply)

  Attended previous year                        Website                                    Mailing

  Neighborhood canvas                          Invited by friend                    Newspaper

  Sign in front of Church                         Poster in Grocery Store   

  Other: