Registration Form

Child's Name

Parent/Guardian Name

Relation to child

Address

Phone

This address will receive a confirmation email

Child's Birthdate

Last Grade Completed

Emergency Contact Information (at least two)

Medical Information (Please include any food allergies)

Dismissal Information (Who may pick up your child each day)

May we have permission to photograph your child?

Yes No

Do you have a home church? Yes No

Description

Breaker Rock Beach VBS is June 9th-13th. Dinner begins at 5:15 each evening and our opening assembly will begin at 6:00. The fun ends each night at 8:30!.

Please fill out this form and click submit.

Registration Form

Description

Please Fix the Following