(One Form Per Child)

Child's name:                                                                                                 

Child's age:                  Date of birth:                                      

Last school grade completed:                  

Name of parent(s):                                                                                           

Street address:                                                                                              

City:                                                       State:                                ZIP:                       

Home telephone:                                       

Parent/caregiver's cell phone:                                

Home e-mail address:                                            

In case of emergency, contact:                                                                              
            

                 Relationship to child:  ________________

Allergies or other medical conditions:

Home church:                                                                                    

Crew number or name (for church use only):

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Go-To Guide granted for local church use. Copyright © 2010 Group Publishing, Inc., P.O. Box 481, Loveland, CO 80539. group.com/vbs