2019 VBS Registration

Parent First Name
Parent Last Name
Street Address
City and State
Zipcode
Home Phone Cell Phone Other Phone
Emergency Contact Name and Phone
List all persons allowed to pick up child.
Child 1 First and Last Name
Gender (Please List Male or Female)
Child 1 Grade Level Completed
Child 2 First and Last Name
Gender (Please List Male or Female)
Child 2 Grade Level Completed
Child 3 First and Last Name
Gender (Please List Male or Female)
Child 3 Grade Level Completed
Do your children have any allergies or medical conditions? Please explain.
Are any of the children you are registering not Baptized?
Would you like to receive our e-newsletter? Please check the box.
Please check the box if you would like a member to tell you more about Shepherd of the Valley.
Use the following field for additional questions or comments.


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