FIESTA!    2006 Vacation Bible School Registration (Please complete one form per child)

Child's Name*:
Date of Birth:			Age*:

Last School Grade Completed:

Street Address*:
City:
State:		AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA MA ME MD MI MN MS MO MT NC NE NH NJ NM NV NY ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Other (Select)	Zip:

Home Telephone*:
E-mail:
Home Church
		Emergency Contact Information*
Mother:
Father:
Other:
		<Allergies / Medical Conditions>

* Denotes Required Field