Registration for VBS 2010

‘The Bread of Life ’

Child's Name		Date of Birth
Age as of 9/1		Grade as of 9/1
T-shirt Size		Gender
Parent's Names
Are Parents Members of PUCC?
E-mail Address		Home Phone
Address
Work Phone		Cell Phone
List an Emergency Contact in case the parents cannot be reached.
Contact		Phone
Please List Allergies or Other Conditions we may need to know about