Valley Community Baptist Church - Childcare Registration

CHILDCARE REGISTRATION
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Use this registration form to register you child(ren) for childcare during Bible studies during the week and Weekday Courses. Please re-register your child for each new study and/or Weekday Course Block.

Child 1 Last Name: First Name:

   Birth date: Month    Day    Year

Child 2 Last Name: First Name:

   Birth date: Month    Day    Year

Child 3 Last Name: First Name:

   Birth date: Month    Day    Year

Child 4 Last Name: First Name:

   Birth date: Month    Day    Year

Father's Last Name: First Name:

Mother's Last Name: First Name:

Street Address:

City:    State:    Zip:

Email Address:

Primary Phone:    Secondary Phone:

Name of study/event parent will be attending:

Please provide specific instructions for special needs/allergies:

Enter the numbers as they
are shown in the image above