VBS Registration Form
Please complete all information.


Child's Name:
Parent(s)' Name:
Address:
City: State: Zip:
Home Phone: Cell Phone:
*Email:
Emercency Contact:
Emergency Phone:

Relationship:

 
Date of Birth: Grade Completed:
Church Relationship: Bethlehem Member BLS Student Visitor
Gender: Female Male
   

My Child has

Food Allergies

Please List:

Other Allergies

Please List:
Asthma
Epilepsy/Seisure Disorder
Diabetes
Frequent Upset Stomach
Frequent Headaches
Physical Handicap
ADD, ADHD, or other Behavior Disorder

Other medical concerns

Please List:
 
I would like a CD of the VBS Music ($8 due at VBS)
Please put my child in the same group as (name of other child):



Comments/Questions: