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Child's Name: *
First Name
Last Name
Child's Gender: *
Child's Age: *
Date of Birth:*
Last School Grade Completed:*
Name of Parent(s):*
Address: *
Address Line 1
Address Line 2
Postal Code
Telephone Number:*
Additional Telephone Number:
Emergency Contact Number (During VBS ~ 6:00 - 8:00 p.m.):*
E-mail Address:*
Allergies or Dietary Restrictions:
Additional Comments: (personality traits, behavioral/sensory concerns, special grouping requests):