* Child's Name:

* Grade Entering:       * Birthday:       * Age:

Parent Information

* Parent's Name:

* Home Address:

* City:       * State:

Zip Code;

Mailing Address (if different from Home Address):

City:       State:

Zip Code;

If home and cell phone are same, fill in home phone:

Home Phone:

Cell Phone:

Email:

Emergency Contact Information:

* Emergency Contact:

Relationship to Child:

If home and cell phone are same, fill in home phone:

Home Phone:

Cell Phone:

* Any food or latex allergies YesNo

Please list:

* Medical Concerns: YesNo

(Explain):

Any siblings attending VBS (please list first name, last name and age)?:

Do you attend Mill-Green UMC? YesNo

Do you attend another Church? SelectYesNo

List of those who may pick your child up:

* I give Mill-Green UMC permission to include my child in any video or photo taken during VBS to be lawfully shared on the church web site and church facebook." NoYes