Child's Name (required)

Grade entering fall of 2010:

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Date of Birth:

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Parent/Guardian Name:

Mailing Address:

Phone Number

Cell Number (if different from above):

Your Email (required):

Church Affiliation (if any):

Allergies or Other Medical Information:

Emergency Contact #1 Name:

Emergency Contact #1 Number:

Emergency Contact #2 Name:

Emergency Contact #2 Number:

Who may pick up this child at the end of the day?

Please list names of friends your child is attending VBX with: