Polar Blast VBS Registration

Please fill out the information below, and someone from our Kidstreet staff will contact you for any additional information! Thank You!

Child's Name:

Child's Age:

Date of Birth:
Month: Day: Year:

Last school grade completed:

Name of parent(s):

Street address:



Zip code:

Home telephone:

Parent/caregiver's cell phone:

Home email address:

Home church:

Allergies or other medical conditions:

In case of emergency, contact:

Emergency contact phone:

Relationship to child: