VBS Registration Form

Child's Name:

Parent or Guardian Name:

Your Email:

Address:

Phone Number:

Child's Birthdate:

Preschool ages before 5/31/2017:
3 yrs before 5/314 yrs before 5/315 yrs before 5/31Kindergarten before 5/31

School grade last attended:
FirstSecondThirdFourthFifthSixth

Gender:
MaleFemale

List any Allergies or put None:

May your child's photo be used by WPBC for promotion, publicity, and media release? yesno