VBS Registration – STELLAR

Child's Name

Birthdate

Grade Just Completed
Age 4Age 5Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade

Parent/Guardian Name(s)

Address

Primary Phone

Secondary Phone

Email

Emergency Contact

Phone Number

Relationship

In case of emergency, do you give consent to obtain medical attention?
YesNo

Doctor's Name

Phone Number

List any allergies or medical conditions we should be aware of:

Who IS allowed to pick up your child?

Is there a specific person who is NOT allowed to pick up your child?

As best you know, will your child be able to attend all five days?
YesNo

If "No", please select the days he/she CAN'T attend
MondayTuesdayWednesdayThursdayFriday

Home church, if any

Invited by

Is there a buddy your child would like to be grouped with?