Antioch Baptist Church

VBS Registration

Child's Name *

Child's Name

First Name

Last Name

Date of Birth

Date of Birth

MM

DD

YYYY

Mother's/Guardian's Name *

Mother's/Guardian's Name

First Name

Last Name

Father's Name

Father's Name

First Name

Last Name

Home Street Address *

Home Street Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Phone

(###)

###

####

Email Address *

Allergies *

If your child has food or drug allergies that our staff should know about please check yes and list allergies below

Yes

No

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