MIDLAND UNITED METHODIST CHURCH

Pastor Dianne D. Vielhuber

10234 Hwy KP, Mazomanie, WI 53560 

CROCODILE DOCK

VACATION BIBLE SCHOOL

JULY 27-31 2009

5:30 TO 8:00 P.M.

All children 3 to 12 years of age are welcome

You may bring your child, July 27 and register at the door, if you are unsure of your week plans. 

REGISTRATION FORM

If possible, please return this form by Friday, July 17 so we can get a rough idea of the ages and number of children attending.

Please return this form to Liz Nelson 208 Glen View Road, Mount Horeb, WI 53572 

Child’s Name: ____________________________________  Age: _________

Date of Birth: __________________  Last school grade completed: _________

ALLERGIES  or other medical conditions: __________________________________

_____________________________________________________________________ 

Child’s Name: ____________________________________  Age: _________

Date of Birth: __________________  Last school grade completed: _________

ALLERGIES  or other medical conditions: __________________________________

_____________________________________________________________________ 

MOTHER: __________________________  FATHER: ________________________

Street address: _________________________________________________________

City: ________________________________ State: _________ Zip Code: _________

Telephone #: ____________________ Email address: __________________________

In case of emergency, contact: _____________________________________________

Who will pick up your child each evening: ___________________________________

I’d love for my child to attend, but I need transportation:  Yes  No   circle one

OR Sign up online