Galaxy VBS July 12, 19, 26

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Child's Name

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Child's date of birth

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Child's last grade completed

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Please select all that apply.

5th 4th 3rd 2nd 1st Kinder TK Preschool

Parent(s) names

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Home Address

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Parent's Phone

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Parent's Email

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This address will receive a confirmation email

Home church

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Contact in case of emergency

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Allergies/Medical info (If none, please type "none")

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OK to publish photos to SouthPoint media

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Suggested donation $5

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Amount

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

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