Child's name:    

Date of birth:    Last completed school grade:

Street: 

City:    State:   ZIP: 

Phone:     Email: 

In case of emergency, contact: 

Relationship to child:    Phone:

Father:      Mother: 

Allergies or medical conditions we should be aware of:

Your home church:  

Has this child ever attended our VBS before?    Yes    No

Ledgewood Baptist Church
233 Main Street
Ledgewood, NJ  07852
973-584-2677
www.ledgewoodbaptist.com

Rev. David Holwick, dholwick@gmail.com

VBS director: Pam Freund