Child's Name *
Child's Name
Child's Date of Birth *
Child's Date of Birth
WRPC VBS is open to rising 1st-6th grades (ages 6-11 by Sept. 1st)
Home Address *
Home Address
Contact Phone *
Contact Phone
Emergency Contact Phone *
Emergency Contact Phone
Doctor's Phone *
Doctor's Phone
In case of medical emergency *
Please certify that you are the parent or legal guardian *