Register me for 
One form per child, please. Print this page and mail to address below or FAX: 520-625-2635
Child’s name_______________________
Grade completed ___________________
Birthday______________ Age ________
Parents’ names ____________________
_________________________________
Address _____________________________________Zip___`___________
Home phone ________________ Cell phone ________________________
Emergency contact person _______________________________________
Relationship to student __________________________________________
Home phone ____________________ Alt. phone _____________________
Food allergies Y
______ N ______ (List:) ___________________________Medical concerns Y ____ N ______ (Explain:) _______________________
_____________________________________________________________
Family doctor _________________________ Phone __________________
Siblings attending VBS (names & ages) _____________________________
_____________________________________________________________
Church affiliation ____________________ Church membership at ________
_____________________________________________________________
People who may pick up the child __________________________________
_____________________________________________________________
Brought by ____________________________________________________
Address ______________________________________________________
City, State, Zip Code_______________________Phone_________________
__
I hereby grant the VBS leaders permission to photograph/film the minor designated above in any manner or form for any lawful purpose Associated with this VBS program.
Buddy the porcupine invites you to join him and his best friend, Alex, on a hike through the mountains, to find Jesus, our
Forever Friend!
conducted at
Lutheran Church of the Risen Savior
555 S. LaCañada Drive
Green Valley, AZ 85614
(520) 625-2612
E-mail: info(at)risen-savior(dot)org
(Please note that we are writing the email address in such a way that Spammers can't harvest it and send us Spam.)