Name* (Please submit one form for each child). Date of Birth* MM slash DD slash YYYY Fall 2022 school grade* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Parent 1Name* ㅤ Daytime phone*Email* Parent 2Name ㅤ Daytime phoneEmail Other caregiver (optional)Name ㅤ PhoneEmail Allergies Please let us know if your child has any allergies we should be aware of. You may also contact us directly to provide this information if preferred. Medical Conditions Please let us know if your child has any medical conditions that may impact their participation. Do not use this form to share sensitive or confidential medical information. You may also contact us directly to provide this information if preferred. Age groups during VBSChildren will be placed into multi-age crews of about 5-7 children each. Each crew will be part of a team comprised of 3-4 crews. Ages four through rising kindergarten will be separated by crew and team from the elementary age children but will be together for the opening and closing each day. We will try to honor requests for your child to be grouped with a sibling or special friend if they are in the same age group. Children will assemble and eat a nut free snack each day. If your child has other food allergies, please feel free to pack them a snackIf there is something regarding a specific need or situation with your child that you would like to discuss with a coordinator, please check this box If there is something regarding a specific need or situation with your child that you would like to discuss with a coordinator, please check this box If you would like to volunteer with VBS, including set up, clean up, or daily help, please check this box If you would like to volunteer with VBS, including set up, clean up, or daily help, please check this box St. Paul’s Lutheran Church has permission to photograph my child during VBS. Photographs will be used for church use and outreach materials only ( St. Paul’s Lutheran Church has permission to photograph my child during VBS. Photographs will be used for church use and outreach materials only ( Parent Electronic Signature ㅤ Please type your full name to confirm registration. Today's Date MM slash DD slash YYYY REGISTRATION DEADLINE: JULY 1. Space is limited. Completed forms may be returned to the church office, St. Paul’s Lutheran Church, Attn: VBS, 7426 Idylwood Rd., Falls Church, VA 22043, or e-mailed to MelissafHecht@gmail.com. Please use the subject line “VBS registration.” Δ
