VBS

NCPC NEWS

Childs Name

Male/Female ?

Child's Age

Date of Birth

Last Grade Completed

Parent/ Gardian Name

Address

City, State, Zip

Home Phone

Cell Phone

Home Email Address

Home Church

In Case Of Emergency (Name)

Relation To Child

Cell Phone

Allergies or Any Other Medical Conditions

Medications (Suchasan Epipen or Inhaler) that will accompany child . (all medications must be clearly markedwith the child's name and dosage)

Other Helpful Notes

I give permission for my child's picture to be taken for publicity use for the church's social media. Yes No

Your email

Check word:

Please Complete the form on this page