1. education
2. school

Pines Presbyterian Church
Vacation Bible School June 22-26, 2015
Student Registration
Registration Deadline is 6/1/2015
Please note: enrollment is limited; acceptance is based on availability at time of registration.
Parents will be notified if classes have reached capacity.
Student name: ______________________________________________________
Street address: _____________________________________________________
City: ____________________ State: __________________ Zip: _____________
Home phone: __________________ Alternative phone: ______________________
Mother’s name: ___________________ Father’s name: ______________________
Child’s Birth Date: ________________ Parent’s E-mail _______________________
Preschool: Age your child is as of June 1st include years and months. For example: 4.6
______________
Elementary: Grade your child will be in starting in the fall __________________
Your child must be 3.5 years of age (and potty trained) by June 1st in order to
participate in the program.
In case of emergency please contact:
Name: ____________________ Phone: _____________ Alt. Phone: ____________
Relationship: _______________
Please list any special needs, medical conditions, or allergies including foods:
____________________________________________________________________
____________________________________________________________________
(see reverse)
Registration is $10 per child or $15 per family of 2 or more. (Scholarships are available
upon request.)
Make checks payable to:
Pines Presbyterian Church
Mail form, with checks to:
Pines Presbyterian Church
Attention: Mary Sterner
12751 Kimberley Lane
Houston, Texas
77024
OR you can bring your forms and money into the church offices.
______________________________ has my permission to attend Pines Presbyterian
Vacation Bible School, June 22nd-26th, 2015 from 9:00-12:00 p.m. In the event that I
cannot be reached in an emergency, I hereby give permission to the physician or EMT
personnel selected to secure and administer treatment including hospitalization for the
participant named above.
_____________________________ Signature of parent or guardian
_____________________________ Printed name of parent or guardian
Insurance company name: _____________________ Policy/group # ________________
Phone number of authorization: ____________ Primary care physician:
_______________
You must fill a form out for each child in a family. Thank you for trusting us with your
child/children. We look forward to having a fantastic week with them.