Child 1 Name *

First Name

Last Name

Child 2 Name

First Name

Last Name

Child 3 Name

First Name

Last Name

Parent 1 Name *

First Name

Last Name

Parent 1 Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent 1 phone *

(###)

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Parent 2 Name

First Name

Last Name

Parent 2 Address (if different)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent 2 phone

(###)

###

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Emergency Contact (not parent) *

First Name

Last Name

Emergency Contact phone (not parent) *

(###)

###

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Photo Permission *

I give St. John's Lutheran permission to use photos of my child for ministry purposes.

Medical Emergency Provision *

I give the leaders of St. John's program leaders permission to medically treat my child both in house and at a medical center if the need should arise. And I know I will be contacted as soon as possible should this happen.

Suggested Registration $10

I intend to pay the registration in advance in the Church Office

I intend to pay the registration on the first night of VBS