Please fill out your information and click 'register' to submit your child's registration for Emmanuel's Power Lab VBS!

Name:
Street Address:		City:	Zip:
Home phone:	() -	Home e-mail address:
Date of Birth:		Last School grade completed:
Mother:		Father:
Allergies or Other Medical Conditions:
Home church:
Name of a special Friend your child might like to be with:
In Case of Emergency, Contact			Phone #: () -
It is understood that every precaution will be taken for the safety and well being of my child, but in the event of an accident or sickness, Emmanuel Baptist Church, its staff, and its volunteers are hereby released from any liability. I agree to the above statement