2010 Pittsgrove Presbyterian Church

VBS REGISTRATION FORM

July 12-16 (one per child)

Name: ____________________________________ Age: ________________

Street Address: _________________________________________________

City: ___________________ State: ________ Zip: _____________________

Home telephone: _________________________________________________

Parent/Caregiver’s cell number _______________________________________

Home e-mail address: ______________________________________________

Child’s date of birth: _______________________________________________

Last school grade completed: ________________________________________

In case of emergency, contact: _______________________________________

______________________________________________________________

Mother: ________________________________________________________

Father: _________________________________________________________

Other: _________________________________________________________

Allergies or other medical conditions: __________________________________

______________________________________________________________

______________________________________________________________

Home church: ____________________________________________________

For more information, contact:

Pittsgrove Presbyterian Church
Ph. 856-358-1104
or visit www.daretownpres.org