KICKIN' IT OLD SCHOOL VBS 2011 ONLINE REGISTRATION FORM

Name of child    Age    Grade Entering in Fall

Mailing Address    

Phone (home) (cell)    Email

Date of birth (child)  Parent or Guardian Name(s)


In Case of Emergency Contact

Special Circumstances (allergies, medical conditions, custodial issues, etc.)


Home Church

How did you hear about Vacation Bible School?


By submitting this form, I hereby authorize the staff of Eagle Point Community Bible Church to render
first aid and/or seek appropiate medical assistance for child named above in the event of a medical
or other emergency.