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Providence United Methodist Church
VBS Registration

2017 VBS Registration June 11th-15th 5:30 – 7:45
Child's Name*
Parent/Guardian Name*
Street Address*
City*
State*
Zip*
Email Address*
Cell Phone*
Home Phone
Child's Age*
Last School Grade Completed
Home Church
Allergies/Medical Info/Other
Emergency Contact (1) Name*
Emergency Contact (1) Phone*
Dismissal Info - Name(s) of person(s) who may pick up child from VBS