Vacation Bible School: Harvest Love

Child(Children)

Child*

First Name*

Last Name*

Age*

Birthdate*

Second Child

First Name

Last Name

Age

Birthdate

Third Child

First Name

Last Name

Age

Birthdate

Child's Address

Address Line 1*

Address Line 2

City*

State*

Zip*

Parent/Guardian

First Name*

Last Name*

Home Phone*

Cell Phone

Email

Medical Insurance?
YesNo

Insurance Company

Policy/Group ID

Child’s Food Allergies and/or Other Medical Information
Place any information you'd like us to know here, including any specific medical/allergy/activity restriction information per child.

Emergency Contact

First Name*

Last Name*

Phone*

Relationship to child*

Permission

By submitting this form, I grant that this child has my permission to attend Vacation Bible School at Mt. Lebanon United Methodist Church, from July 31 — August 4 from 9:30 a.m. — 11:30 a.m. MLUMC also has my permission to have emergency care provided to my child, if necessary.

How Did You Hear About Us?*

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