Please fill out the form below to sign up for this year's summer VBS at Immanuel Baptist Church.

Child's First Name:

*

Child's Last Name:

*

Birthdate:

*

Gender:

Boy    Girl

Grade (completed):

*

Food Allergies:

*

Email:

*

Confirm Email:

*

Mailing Address:

*

City:

*

State:

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

Zip:

*

Emergency Contact:

*

Emergency Phone #:

*

Mom's First Name:

*

Mom's Last Name:

*

Mom's Cell:

*

Dad's First Name:

*

Dad's Last Name:

*

Dad's Cell:

*

Where do you regularly attend church? *

Please know that while attending, Immanuel Baptist Church may take photos and/or videos to use for Friday's Parent Night, publicity, informational purposes, and public viewing on printed materials or the internet.