2019 - VBS Registration

Child Information

Child's Name

Child's Birthday:

Allergies:

Parent Information

Name:

Email:

This address will receive a confirmation email

Phone:

Address:

Emergency Contact

Name:

Relationship to Child:

Phone Number:

Payment

If you are registering four or more of your children, please contact Denise before making your payment: denise@nepres.org

Payment $25.00

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

June 17-21; 9:00am - noon

Please fill out this form to register your child for VBS. One form per child, please.