Mt. Harmony One-Day VBS @ MLM Warehouse

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Join us for Mt. Harmony's One-Day VBS at the My Life Matters Warehouse

Saturday, Sept. 19, 2020
10 a.m. - 4 p.m.

My Life Matters Warehouse
80 Danwin Lane
Roxboro, NC 27573

*Students will be screened at check-in following school guidelines.*

First Name *

Last Name *

Birth date *

YYYY

Age *

Last Grade Completed *

Kindergarten

First

Second

Third

Fourth

Fifth

School *

Gender *

Male

Female

Local Church *

Parent First Name *

Parent Last Name *

Parent Phone Number *

Parent Email *

Additional Emergency Contact (First Name) *

Additional Emergency Contact (Last Name) *

Additional Emergency Contact Phone Number *

Student Address (Address, City, State, Zip) *

Allergies/Medical Notes *

Medications and Instructions - Please be specific *

Insurance Company *

Insurance Policy Holder *

Insurance Policy Number *

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