Vacation Bible School
Registration Form

Cicero Christian Church

VBS 2011

June 13-17, 2011
6:30-8:45pm

for children age 4 through grade 5 (entering in fall)

one child per form

If more than one child is participating,
complete this form then use your
back button to register more.

  
First Name:  
Last Name:  
Birth Date: / /  
Grade in Fall:





 
Street Address:  
P.O. Box or Apartment:  
City:  
State:  
Zip Code:  
Home Phone Number: ( ) -  
Church Affiliation:

None

Other:

 
Other Church Name:  

 

  
First Name:  
Last Name:  
Address:

Is DIFFERENT from the child

 
Street Address:  
P.O. Box or Apartment:  
City:  
State:  
Zip:  
Home Phone: ( ) -  
Mobile Phone: ( ) -  

this information is for emergency contact,
not to register the father to attend

 
First Name:  
Last Name:  
Address:

Is DIFFERENT from the child

 
Street Address:  
P.O. Box or Apartment:  
City:  
State:  
Zip:  
Home Phone: ( ) -  
Mobile Phone: ( ) -  
   
Emergency Contact:




 
First Name:  
Last Name:  
Phone: ( ) -  
Relationship to child:  
   
Allergies/illness/special needs:


 
Anything else you would like us
to know about your child or family? 		 

There is an error with your form. Please fix the areas identified in red.

Cicero Christian Church - 1715 Stringtown Pike - Cicero, IN 46034