St.

Matthew Lutheran Church

Vacation Bible School Registration Form

August 2-6, 2010 6:00 - 8:30 p.m.

Please return this form no later than July 21, 2010

Submit form to: St. Matthew Lutheran Church
1200 Churchville Road, Bel Air, MD 2 1014-3412

Enrollment is for children who have completed Age 3 or 4 pre-school and are toilet trained
through those students who have completed 5th grade.

REGISTRANT(S):

Child's Name: Age:

Date of Birth: Last Grade Completed:
Allergies/Important Medical Information:

Child's Name: Age:

Date of Birth: Last Grade Completed:
Allergies/Important Medical Information:

Child's Name: Age:

Date of Birth: Last Grade Completed:
Allergies/Important Medical Information:

CONTACT INFORMATION:

Mother's Name: Father's Name:

Address: City/State/Zip:
Home Phone:
Mother Cell Phone:
Father Cell Phone:
E-Mail Address:
St. Matthew Church Member? Yes No If you are not currently a member, would you like to be
contacted to learn more about our church? Yes No

EMERGENCY CONTACT INFORMATION (other than parent):

Name: Relationship to child:

Cell No.:
Home Phone:
Work Phone:

DISMISSAL INFORMATION
Person(s) Authorized to pick up child(ren):
Contact Phone Number(s):

For questions contact: Julie McDonnell, Cell Phone: 443-220-6942, E-mail: scraps4abc@verizon.net