Emmanuel is offering VBS from 8am-11:30am on June 3-7, 2019. This is for boys and girls age birth through Kindergarten. Please complete the form below to submit your registration. Child's Name* First Last Child's Gender*Please SelectMaleFemaleChild's Date of Birth* MM DD YYYY Child's Age*Child's T-shirt Size*Please SelectYXSYSYMYLFather's Name* First Last Mother's Name* First Last Legal Guardian's Name* First Last Home Phone Number*Cell Phone Number*Work Phone Number*Email Address* Emergency Contact - Name* First Last Emergency Contact - Phone Number*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do any of the following health history related items apply to your child? (Please select all that apply)* Allergy Chronic Asthma Diabetes Drugs Epilepsy Frequent Colds Frequent Stomach Upsets Heart Insect Stings Physical Handicap Other None of these apply Are there any special concerns or circumstances you would like your child's team leader to be aware of prior to your student's arrival at VBS?*Please SelectYesNoIf yes, please explain*Do you aknowledge that EBC has permission to use any image of your child made with others at camp or any written material that he/she may write about camp for promotional purposes?* Yes List the name(s) of the individual(s) who have permission to pick up your child from VBS at the end of each day:*NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.