Registration Form

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Vacation Bible School Registration Form United Presbyterian Church 2400 W. Northmoor Rd. * Peoria, IL 309.693-2002 * www.unitedpc.org

Cost is $10/child and max $20/family Ages 4 – entering 6th grade Kids entering 6th grade can choose to be Jr. Camp Leaders Submit this form and payment to office Scholarships available – contact Karen Miller

July 15 – 19 6:00 – 8:15 PM Name:

Age:

Birthdate:

Grade Entering:

T-Shirt Size:

Parents Names: Home Address: Phone:

Email:

Emergency Contact:

#:

Food Allergies: Y N (circle one) Please List: Medical Concerns: YN (circle one) Please List: Home Church: I hereby grant the VBS leaders permission to photograph/film the minor(s) designated above in any manner or form for any lawful purpose associated with the VBS program. Parent Signature: *Please note any special needs/requirements your child may have so we can make sure they have the best week possible. **All special grouping requests are not guaranteed. No cross age group requests allowed due to specific programming for certain age groups.