VBS 2017- SHEMA Registration

Child's Name (First & Last):*
Child's Gender*
 Male
 Female
Child's Age*
Date of Birth:*
Last School Grade Completed:*
Name of Parent(s):*
Street Address:*
City:*
State:*
Zipcode:*
Home Telephone:*
Parent/Caregiver's Cell Phone:*
E-mail Address:*
Home Church:*
Crew number or name (for church use only):
Allergies or other medical conditions:*
In case of emergency, contact:*
Phone:*
Relationship to child:*


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