Parent or Guardian Name *

Parent or Guardian Name

First Name

Last Name

Phone Number *

Email Address *

Alternative Emergency Contact

First Name

Last Name

Phone Number

Family Doctor

First Name

Last Name

Phone Number

Child's Name #1

First Name

Last Name

Grade This Fall

Date Of Birth

Male

Female

Allergies:

Child's Name #2

First Name

Last Name

Grade This Fall

Date Of Birth

Male

Female

Allergies

Child's Name #3

First Name

Last Name

Grade This Fall

Date Of Birth

Male

Female

Allergies

Child's Name #4

First Name

Last Name

Grade This Fall

Date Of Birth

Male

Female

Allergies

Media Consent:

Yes

Please Add Me To The Children's Mailing List

Yes

Music CD $2

Payment due upon pickup at VBS

Children's T-Shirts Cost: $5

Payment due upon pickup at VBS

Youth Small

Youth Medium

Youth Large

Adult Small

Thank you! We are looking forward to seeing you this summer. Questions/Comments:

VBS Registration Form 2017

SALEM FIRST

1550 MARKET ST. NE SALEM, OREGON 97301 - 503-581-3680 - INFO@SALEMNAZ.ORG