Vacation Bible School Registration

 

Child Information

Child Name: *

Birthdate: * (mm/dd/yyyy)

Age:

Gender: Boy Girl *

 

Parent / Legal Guardian Information

Parent / Legal Guardian Name: *

Email: *

 

Contact Information

  Address: *
  City: *
  State: *
  Zip Code: *
  Primary Phone: *
  Secondary Phone:

 

Additional Information

Are there any special conditions of which we should be aware?

Yes No

Additional Information (Please include information concerning special conditions)

 

       
 
 
 
 
1008 East Emerson St Bloomington, IL 61701   |   contact@bloomingtonbiblechurch.org   |   (309) 829-4565