Vacation Bible School 2017

June 19 to June 23, 2017, 9:30am to 12:00pm | Immaculate Conception, Ira Twp

Parent Name

*

Email

*

This address will receive a confirmation email

Phone

*

Address

*

Emergency Contact Name

*

Emergency Phone

*

Emergency relationship to child

*

1. Child's First & Last Name

*

Child's Age

*

Please select one option.

4 5 6 7 8 9 10 11 12

Child's Grade in the Fall

*

Please select one option.

4 Yr Old Pre-School Kdg Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6

2. Child's First & Last Name

Child's Age

Please select one option.

4 5 6 7 8 9 10 11 12

Child's Grade in the Fall

Please select one option.

4 Year Old Pre-School Kdg Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6

3. Child's First & Last Name

Child's Age

Please select one option.

4 5 6 7 8 9 10 11 12

Child's Grade in the Fall

Please select one option.

4 Year Old Pre-School Kdg Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6

4. Child's First & Last Name

Child's Age

Please select one option.

4 5 6 7 8 9 10 11 12

Child's Grade in the Fall

Please select one option.

4 Year Old Preschool Kdg Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6

I would like to help with VBS

Please select all that apply.

Adult over 18 Teen (Grade 9-12) Youth (Grade 7-8)

Adults: I have attended Protecting God's Children Workshop

Please select all that apply.

Yes No

Teens: I have attended Called to Serve Workshop

Please select all that apply.

Yes No

I have a background check on file at Immaculate Conception, Ira Twp

Please select all that apply.

Yes No

FREE: I would like to attend the Bible Study that coincides with this year's VBS theme

Please select all that apply.

Yes No

Payment

1 Child ($15.00) 2 Children ($30.00) 3 or more Chidren ($35.00)

Amount

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

June 19 to June 23, 2017, 9:30am to 12:00pm

Immaculate Conception, Ira Twp

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