VBS Registration – Slippery Rock Baptist Church

Child Information

Name *

First

Last

Date of Birth

Name (copy)

First

Last

Date of Birth (copy)

Name (copy) (copy)

First

Last

Date of Birth (copy) (copy)

Parent/Guardian Information

Name *

First

Last

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Medical Concerns or Allergies