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Child's Information:

*First Name:

*Last Name:

*Age:

*Gender:
  Male Female

*Entering Grade:
(Leader positions require an additional application available from the CE Director.)
  Pre School Kindergarten 1st 2nd 3rd 4th 5th MS Participant (entering grades 6-8) Teen Leader (7th grade and up.)

*Street Address:

*City:

*State:

*Zip Code:

*Allergies and/or Medical Conditions:
Enter none below if this does not apply to your child.

What church do you regularly attend/are a member of?
  First UPC Other None

If church other than 1st UPC, which one?

Guardian's Information:

*Contact Email Address:

*Re-Enter Email Address:

*1st Parent/Guardian Name:

*Home Phone:

*Cell Phone:

Work Phone:


  I want to volunteer to help.
  I want to donate snacks to VBS.

2nd Parent/Guardian Name:

Home Phone:

Cell Phone:

Work Phone:

Emergency Contact Other Than Guardians:

*Name:

*Emergency Contact Phone:

Relationship To Child:
  Grandparent Aunt/Uncle Other Family Member Family Friend

People able to pick up/drop off child (in addition to guardians):

Name(s):

You aren't finished yet!

1. Please complete the health history (a new form must be completed each year). Health History Form

2. Bring payment, completed health history, and pick up your music CD at 1st UPC by the Monday before VBS begins.

117 N. Main St., Bellefontaine OH 43311 (use rear entrance)
937-592-6611