Shake it Up Café Registration Form

ECUMENICAL VACATION BIBLE SCHOOL

August 1– 5, 2011
Location: Good Shepherd Lutheran Church
547 Saratoga Road
Glenville, NY 12302
Dates: Monday, August 1st - Friday, August 5th
Time: 8:45 a.m. - 12:15p.m.
Registration Fee: $20 per child ($60 family maximum)

Child’s Name (#1) ________________________________ Grade Entering* ____________ Age: _____

Child’s Name (#2) ________________________________ Grade Entering* ____________ Age: _____

Child’s Name (#3) ________________________________ Grade Entering* ____________ Age: _____

*Must be entering Kindergarten thru sixth grade in September

By registering your child, you are agreeing to allow photos of your child to be taken for promotional use.

Parent/Guardian Name: _______________________________________________________________

Address: ______________________________________ Home Phone: _________________________

______________________________________ Work/Cell Phone: _____________________

Email Address (please check for updates): ________________________________________________

Home Congregation (if any): ____________________________________________________________

In case of emergency (when parent/guardian cannot be reached) please contact:

Name: ____________________________________________________________________________
Telephone: _________________________________________________________________________
Relationship to Child:__________________________________________________________________
Child’s Physician: _________________________ Phone Number: __________________________
Please list any known allergies or special needs that the VBS staff should be made aware of:
___________________________________________________________________________________
Person responsible for picking up child at the end of each VBS day:

Name: __________________________________ Phone Number: ____________________________

Signature of Parent/Guardian: ________________________Security Code Word for Pickup:_________

Return this form along with the registration fee to your church office or mail to:
VBS DIRECTOR c/o Good Shepherd Lutheran Church, 547 Saratoga Rd, Glenville, NY 12302

*Checks Payable to Burnt Hills Inter Church Council*

Shake it Up Café Vacation Bible School Affiliates:
Good Shepherd Lutheran, Our Lady of Grace, Immaculate Conception, Burnt Hills Baptist,
Burnt Hills United Methodist, Charlton Freehold and Calvary Episcopal Churches.

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