VBS Registration | St. Luke's UMC Midland

Child's name:

First Name

Last Name

Child's gender:

Child's age:

T-Shirt Size

Date of birth:

Last school grade completed:

Name of parent(s):

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home telephone:

Parent/caregiver's cellphone:

Home email address:

Home church:

Allergies, medical conditions, or special needs:

In case of emergency, contact:

Emergency Contact Phone:

Relationship to child: