St. John's Lutheran Church
815-338-5159
Register me for
PLANET ZOOM
(One form per child, please)
* Child's Name:
* Grade Completed:
* Birth Date:
(mm/dd/yyyy)
* Age:
* Parent's Name:
* Address:
* Home Phone:
(include area code)
Cell Phone:
(include area code)
* Emergency
Contact:
* Relationship
to Student:
* Home Phone:
(include area code)
Alt. Phone:
(include area code)
* Food Allergies or Other Medical Problems
(please list):
* Family Doctor:
* Phone:
(include area code)
Siblings Attending VBS (names and ages):
Church
Affiliation:
Church
Membership:
* Persons who may pick up the child
(please list full name of each person):
Attendance
1 2 3 4 5
By clicking the SUBMIT button below, you give permission for any photos taken of the child being registered during the course of Vacation Bible School to be used in newspaper articles, website publications, and/or other media. No personal information about the child (name, address, age, etc.) will be published.
