VBS Registation

Name of Child

First Name

Last Name

Date of Birth

YYYY

Grade Completed

Age

Siblings Attending

Please include their names and ages on the line below

Parent/Guardian

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Emergency Contact Name & Number

Special Needs / Allergies / Other Concerns

Is there a friend your child would like to be with?