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VBS 2007 REGISTRATION FORM July 9—13 9:00 am – Noon ( *child must be toilet
trained Please list grade child will be entering in the fall.
(Current 5th graders are more than welcome to attend.) If not yet in elementary school, please
just list the child’s age. Name:
_______________________________ Grade: ______
Age: ______ Name:
_______________________________ Grade: ______
Age: ______ Name:
_______________________________ Grade: ______
Age: ______ Name:
_______________________________ Grade: ______
Age: ______ Parent/Guardian:
_____________________________________________ Email: _____________________________________________________ Home Phone
(___)_________________ Cell Phone
(___)______________ Address:
_______________________________________________________
_______________________________________________________ Please list
name of an Emergency Contact and Phone Number (other than
the person
listed above): Emergency Contact: ________________________Phone: (___)____________ The bearer
of this letter has my permission as parent or legal guardian to act on my
behalf in any emergency dealing with the health and welfare of my child and
to obtain emergency treatment for them by a licensed physician. __ No __ Yes
Parent/Guardian Signature: __________________________ Physician’s
Name: _________________________ Phone: (___)___________ Please list
special health considerations (e.g. asthma, seizures, food allergies): Name: ______________ List: _____________________________________ Name: ______________ List: _____________________________________ Name: ______________ List: _____________________________________ Name: ______________ List: _____________________________________ Please list
the name(s) of person(s) you give permission to pick up your child/children
from Can pick-up
my child/ren:
______________________________________ Can pick-up
my child/ren:
______________________________________ Can pick-up
my child/ren:
______________________________________ Are you a
member of this church? __ Yes __ No If not, please tell us how you heard about our __ through a RCLPC church member __ friend __ cable public access
channel __ Daily Herald __ Northwest Herald __ Park District sign __ church
web site __ the church I currently attend __ saw a sign
from the road (name of church) _________________________________________ __ other (please
specify) ________________________________________ Cost of VBS
is $15.00 per child for first 2 children, and then $7.50 for each additional
child. (Scholarships are available. Call the church office at 815-459-1132.) Number of
children registering: _____ Total
Enclosed: $______
Please make check payable to RCLPChurch. DO
NOT SEND CASH through the mail. “Lift Off” Soaring to New Heights with God Mail or bring in this registration
form with payment to: Ridgefield-Crystal
Lake Presbyterian Church Office: 815-459-1132 (located
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