Peace Lutheran Church VBS Registration Form

PEACE LUTHERAN CHURCH

VACATION BIBLE SCHOOL
1801 Port Malabar Blvd Palm Bay, FL 32905

(321) 727-3131
JULY 7 - 11, 2025

9:00AM - 12:00PM

Ages: 4-12

COST: FREE!!!

(Limit of 75 children. Please register early to ensure a place for your child/children)

Last day of online registration: Friday, July 4th at 5:00PM
Parents Name*

PrefixFirst NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
example@example.com
Phone Number*
Cell Number
Emergency Contact *

First NameLast Name
Phone Number*
Cell Number
Child 1*

First NameLast Name
Birth Date*

MonthDayYear
Age:*
Grade Level Completed*
Allergies *
**Please pack a snack for your child if he/she has food allergies.**
Child 2

First NameLast Name
Birth Date

MonthDayYear
Age:
Grade Level Completed
Allergies *
**Please pack a snack for your child if he/she has food allergies.**
Child 3

First NameLast Name
Birth Date

MonthDayYear
Age:
Grade Level Completed
Allergies *
**Please pack a snack for your child if he/she has food allergies.**
Child 4

First NameLast Name
Birth Date

MonthDayYear
Age:
Grade Level Completed
Allergies *
**Please pack a snack for your child if he/she has food allergies.**
Please list any special needs, special diet, medications, etc. that your children may have: PLEASE NOTE THAT WE CANNOT ADMINISTER MEDICATIONS AT VACATION BIBLE SCHOOL!*
IMPORTANT NOTE: People that are allowed to pick-up your child at the end of the day, MUST show identification and their names must be on the list. There are NO exceptions! You must call the office at (321)727-3131 between the hours of 8:30AM – 12:30PM, if you are adding/taking someone’s name off of the list. PLEASE ADD THE NAME/NAMES OF THE PEOPLE/PERSON BELOW WITH PHONE NUMBER INFORMATION.*
Is your child allowed to have his/her picture taken in conjunction with Vacation Bible School?*

YesNo
PARENTS ARE ENCOURAGED TO VOLUNTEER ONE, TWO DAYS (OR MORE). Any questions, ask below:
What day's are you available?

MondayTuesdayWednesdayThursdayFriday
Should be Empty:

PEACE LUTHERAN CHURCH

1801 Port Malabar Blvd Palm Bay, FL 32905