LS VBS

Child's Name*

Child's Age*

Grade during Upcoming School Year (2018-2019)*
PreschoolKindergartenFirstSecondThirdFourthFifthSixth

Birthdate*

Address*

City*

State*
MOKS----

Zip*

Name of Parent/Guardian*

Phone Number*

Email*

Emergency Contact and Number*

Allergies/Health Concerns*

People Authorized to Pick Child Up

T-Shirt Size ($6.00)
Youth Extra Small (2-4)Youth Small (6-8)Youth Medium (10-12)Youth Large (14-16)

Music CD ($7.00)
12None

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Email address

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