Registration Instructions:

Fill out the form below. You can register up to five children. If you need to register
more than five, please fill out a second form.
Once you have submitted your form, a summary page will pop up.
Click the link at the top of your summary page to be taken to our online banking page
where you can pay with Visa, Mastercard or bank transfer.
On the online banking page, check the box marked "2012 VBS", enter the appropriate
amount ($15.00 per child, maximum $40.00 per family) and fill out your personal information
(Our online banking is completely secure). You will receive a receipt via email.
Questions? Send email to countrysidevbs@hotmail.com

So let's get started:


VBS Registration
Child 1 Name
Elementary or Preschool?	Elementary Preschool
If elementary, entering what grade?
Date of Birth
Known allergies or health concerns?
Is there anyone they would like to be in a group with?
Name of Parent or Guardian
Street Address
City
Zip Code
Primary contact phone number
Alternate phone number
Email Address
Name of home church
People authorized to pick up your child
ADDITIONAL CHILDREN
Child 2 Name
Elementary or Preschool?	Elementary Preschool
If elementary, entering what grade?
Date of Birth
Known allergies or health concerns?
Is there anyone they would like to be in a group with?
Child 3 Name
Elementary or Preschool?	Elementary Preschool
If elementary, entering what grade?
Date of Birth
Known allergies or health concerns?
Is there anyone they would like to be in a group with?
Child 4 Name
Elementary or Preschool?	Elementary Preschool
If elementary, entering what grade?
Date of Birth
Known allergies or health concerns?
Is there anyone they would like to be in a group with?
Child 5 Name
Elementary or Preschool	Elementary Preschool
If elementary, entering what grade?
Date of Birth
Known allergies or health concerns?
Is there anyone they would like to be in a group with?