Child's Name:   Parent/Guardian:

Address: City: State: Zipcode:

Phone Numbers/Email

Home: Work: Cell: Email:

Birthdates:

Pre-schoolers only: All others, grade completed:

Emergency Contact:

Name: Phone#:

Medical Information, food allergies or anything else we should know:

Transportation:

Provide own: Transportation Needed: If needed, pick-up address if different from above:

Drop-off address, if different from above:

Who may pick-up your child each VBS day?

Contact us for more information

Eastland Baptist Church

1229 E. High Street   Bryan OH 43506

419-636-3835