VBS will be held at Presbyterian United Church of Christ
858 7th Ave SE, Le Mars, IA 51031
June 17 - 20  from 8:00 am - 12:00 pm
3 years old - students entering 6th grade
Child must be 3 yrs old by June 1, 2019 and potty trained
Friends are welcome!
Registration ends on May 31st.
A program for parents will be held on June 20th at 12 pm @ Presbyterian United Church of Christ.
858 7th Ave SE, Le Mars, IA 51031
If registering online, please print and return the signed (parent & student)
VBS Covenant Form to the church, before/or the first day of VBS.
VBS Registration & Health Form
Grade Completed
Birth Date
1st Time Attending VBS
Yes No
Address, City, St, Zip
Parent/Guardian Name
Work Phone
Emergency Contact and Phone #
Siblings Attending VBS
Church & City You Attend
Chronic or recurring illness or medical condition that may affect VBS life.
Allergies (i.e. food allergies, bee stings, etc.)
Dietary restrictions (i.e. vegetarian, lactose intolerant)
Other suggestions that may help make your VBS week more comfortable and enjoyable.
Medications (please list kinds and dosage)
All pertinent medication must be brought to the VBS Director in their original containers.
Insurance Company
Policy #
Holder's Name
Family Doctor
Immunizations (Yes or No)
DPT (series of 3)
Yes No
Polio Immunization
Yes No
MMR (Measles/Mumps/Rubella)
Yes No
Date of last Tetanus
Yes No
I give my permission for my child to participate in all aspects of the VBS program. I understand that every effort will be made to contact me if my child needs emergency medical treatment.
I authorize medical personnel, the VBS Director or staff to secure any medical or emergency treatment as deemed necessary for my child. I or my insurance company will pay for any medical treatment if costs are incurred.
I give permission for any picture or video taken of my child to be used for promotional purposes.
By choosing "yes" I agree to the above statements.
I would like to be a volunteer. Please list name and phone #.
Optional Attachment
Description for File
Attach a File