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:


City:


State:


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: