Register

Child's First Name:
Child's Last Name:
Date of Birth:
Grade Completed:
Age:
Parent's First Name:
Parent's Last Name:
Address:
City:
State:
zip:
Home Phone:
Cell Phone:
E-mail:
Emergency First Name:
Emergency Last Name:
Emergency Phone:
Is there a special friend your child would like to be with?
Special Needs / Allergies:
Person Responsible for Pickup after VBS:
Their phone number:
Relationship to child:
If registering a child with SPECIAL NEEDS, please complete the following 6 questions. Please specify your child's specific diagnosis
Is your child on medication?
Describe your child's behavior (ex: aggressive, run away, likes to be alone...)
List child's likes/dislikes.
How does your child communicate (speech, sign language, language board, etc.)?
Does your child have trouble transitioning from place to place?