Vacation Bible School

“Mystery Island”

August 3-7

For children age 4-entering grade 7

9:30-Noon

Each child who registers receives a free “Mystery Island” t-shirt, and each family receives a “Mystery Island” music CD on the first day of VBS.

To register, call 920-533-5123 or submit the form below.

Mystery Island

* Child's Name

* Gender

Male

Female

* Child's Birthdate

* Grade Entering

* Age

* Address

Street Address

Address Line 2

City

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State

ZIP Code

* Parents/Guardian Name

* Home Phone

Work Phone

Cell Phone

Email

* Emergency Contact Name (if parent can't be reached)

* Relationship to Child

* Emergency Contact Phone

Name of home church

* Food Allergies

Yes

No

List

* Medical Concerns

Yes

No

Explain

* Shirt Size Please Select: Child Extra Small Child Small Child Medium Child Large/Adult Small