Elementary VBS Registration

AGES 5-12 Y.O. ONLY

Child's First Name

Child's Last Name

Child's Date of Birth

Child's Age

Sex



Address

City

State

Zip

Parent or Guardian's name

Phone

Parent's Email

Emergency Contact Name

Emergency Contact Number

Person (other than parent) allowed to pick up child

Phone number

Does child have allergies? If yes, to what?

Enter the numbers from the image:



          
174 Holmes Street, New Jersey, 07109, United States
973-759-0726
sc