Bethany Baptist Church Vacation Bible School Registration
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Name
First Name
Last Name
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone
*
-
Area Code
Phone Number
E-mail
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Child 1 Name
*
First Name
Last Name
Child 1 Last Grade Completed
*
Pre-K (3 yrs old)
Pre-K (4 yrs old)
Pre-K (5 yrs old)
Kindergarten
1st
2nd
3rd
4th
5th
6th
Child 1 Birthdate
*
-
Month
-
Day
Year
Date
Child 1 Allergies/Special Needs
Child 2 Name
First Name
Last Name
Child 2 Last Grade Completed
Pre-K (3 yrs old)
Pre-K (4 yrs old)
Pre-K (5 yrs old)
Kindergarten
1st
2nd
3rd
4th
5th
6th
Child 2 Birthdate
-
Month
-
Day
Year
Date
Child 2 Allergies/Special Needs
Child 3 Name
First Name
Last Name
Child 3 Last Grade Completed
Pre-K (3 yrs old)
Pre-K (4 yrs old)
Pre-K (5 yrs old)
Kindergarten
1st
2nd
3rd
4th
5th
6th
Child 3 Birthdate
-
Month
-
Day
Year
Date
Child 3 Allergies/Special Needs
Child 4 Name
First Name
Last Name
Child 4 Last Grade Completed
Pre-K (3 yrs old)
Pre-K (4 yrs old)
Pre-K (5 yrs old)
Kindergarten
1st
2nd
3rd
4th
5th
6th
Child 4 Birthdate
-
Month
-
Day
Year
Date
Child 4 Allergies/Special Needs
Will Someone Else Be Dropping Off/Picking Up Your Child?
*
Yes
No
Name Of Drop Off/Pick Up
First Name
Last Name
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