Register below: Please contact us at southsalemchurch@gmail.com if you would prefer a paper copy.

JulY 21st Monday - 25th Friday 9:30am-11:30am

(Please Register By Saturday July 11th)

Attendee #1

First Name

Last Name

Birthday Month and Year / Grade Level in the Fall

Attendee #2

First Name

Last Name

Birthday Month and Year/ Grade Level in the Fall

Attendee #3

First Name

Last Name

Birthday Month and Year/ Grade Level in the Fall

Attendee #4

First Name

Last Name

Birthday Month and Year/ Grade Level in the Fall

Attendee #5

First Name

Last Name

Birthday Month and Year/ Grade Level in the Fall

Address

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone

(###)

###

####

Emergency Contact

First Name

Last Name

Phone Number

(###)

###

####

How did you hear about the South Salem Church of Christ VBS?

Photography

Photographed (still and video). Said photographs/videos might be accessible via internet without being "tagged" or individuals being identified.

Medical Treatment

Medically treated by first-aid-trained staff in case of emergency of if the parent or alternate contact cannot be reached. If deemed necessary by staff, 9-1-1 may be contacted prior to parent or alternate contact notified.

Medical Concerns/Allergies/Miscellaneous Special Needs

Specific medical concerns: Please specify childs name and specific medical concerns.