VBS Sign Up
Please fill out this form and click submit.
Child Information
Child's Name
*
Grade Leaving or Age 3 or 4
*
Date of Birth
*
Allergies
*
Medical Concerns
*
Parent/Guardian Information
Parent/Guardian Name 1
*
Email
*
This address will receive a confirmation email
Parent/Guardian Phone #1
*
Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
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OK
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OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Parent/Guardian Name 2
Parent/Guardian Phone #2
Parent/Guardian Email 2
Emergency Contact Name
*
Emergency Contact Phone
*
Alternate Pick Up Name
*
Alternate Pick Up Phone
*
Alternate Pick Up 2 Name
Alternate Pick Up 2 Phone
Do you have friends you would like to be placed with? We will do our best to group selected friends together in the same group, but we cannot promise all requests will be possible.
Friend 1 Name
Friend 2 Name
Submit
Description
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