Date of birth*
Grade CompletedPreschool (Age 4 & 5)Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeParent's Name(s)*Preferred Phone*Cell PhoneIn case of emergency, please provide cell number. Thank you. Address*
Address Line 2
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific
Church Home (If applicable)Emergency Contact*
If you are unable to be reached, who should we call during VBS hours? Emergency Contact Primary Phone (Cell, Home, etc)*Provide number which best to reach emergency contact. Secondary Phone (Cell, home, etc)*Provide a back up number to reach emergency contactNames of individuals allowed to pick up child from VBS:*Food Allergies?*
Please list allergies:*Medical Needs*
What medical needs does you child have?One friend your child would like to be grouped with (If applicable)Would you like to volunteer?
What would you like to do?*
Be a Center Leader/Helper
Be a Guide
Will you need childcare?
I give permission to Asbury UMC to use any photographs or video taken of my child on their website or any future Asbury publications.
I DO NOT give permission to Asbury UMC to use any photographs or video taken of my child on their website or any future Asbury publications.
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