Emmaus 2019 VBS Registration
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Child's Name *
Gender *
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Birthdate *
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DD
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YYYY
Grade Completed *
Address *
City/State *
Zipcode *
Parents/Guardian *
Home Phone
Work Phone
Cell Phone *
Emergency Contact *
Name/Relationship/Phone #
Food Allergies *
Please list food allergies
Medical Concerns *
Please list medical concerns
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