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Child Information
Child 1
Child First Name
*
Child Last Name
*
Birth Date (must be 4 years or older)
*
+
Gender
*
M
F
Grade Just Completed
*
Pre-Kindergarten
4 Year Old Kindergarten
5 Year Old Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
Allergies/Other Info
*
Child 2
Child First Name
Child Last Name
Birth Date (must be 4 years or older)
+
Gender
M
F
Grade Just Completed
Pre-Kindergarten
4 Year Old Kindergarten
5 Year Old Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
Allergies/Other Info
Child 3
Child First Name
Child Last Name
Birth Date (must be 4 years or older)
+
Gender
M
F
Grade Just Completed
Pre-Kindergarten
4 Year Old Kindergarten
5 Year Old Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
Allergies/Other Info
Child 4
Child First Name
Child Last Name
Birth Date (must be 4 years or older)
+
Gender
M
F
Grade Just Completed
Pre-Kindergarten
4 Year Old Kindergarten
5 Year Old Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
Allergies/Other Info
Child 5
Child First Name
Child Last Name
Birth Date (must be 4 years or older)
+
Gender
M
F
Grade Just Completed
Pre-Kindergarten
4 Year Old Kindergarten
5 Year Old Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
Allergies/Other Info
Child 6
Child First Name
Child Last Name
Birth Date (must be 4 years or older)
+
Gender
M
F
Grade Just Completed
Pre-Kindergarten
4 Year Old Kindergarten
5 Year Old Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
Allergies/Other Info
Parent/Guardian Information
Relationship to Child:
*
Parent
Grandparent
Other
Other
First Name
*
Last Name
*
Address 1
*
Address 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip
*
Primary Phone Number
Additional Emergency Contact Name
Additional Emergency Contact Phone Number
Primary Email Address
*
Additional Individuals Authorized to Pick Up Child
*
My child has permission to participate in the LBC 2019 Vacation Bible School, June 30 through July 3, 2019 (and if church transportation is selected by parent, to be transported by bus, van, or private car). I indemnify and waive any claim against Landmark Baptist Church and Landmark Christian Academy, its employees, and agents for liability or medical payments resulting from my child participating in Vacation Bible School. In the event that my child is involved in any type of injury, accident, or illness, or other situations that may require immediate medical attention, I give permission for my child to be treated by a licensed physician.
*
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