20 Chestnut Street, Centereach, NY 11720
631-585-8760
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Vacation Bible School Registration Form 2022
Child /Children’s information (Please fill out one form per family)
Registration fee $50/children $25 junior counselors $100 family max
Family Name
*
How many children in grades k-6 are you enrolling?
*
Please select...
0
1
2
3
4
5
6
How many junior counselors grade 7 & up are joining?
*
Please select...
0
1
2
3
4
5
6
7
Child 1 First Name
*
Child 1 Last Name
*
Child 1 D.O.B
*
MM slash DD slash YYYY
Child 1 M/F
*
M
F
Child 1 grade in september
*
k
1st
2nd
3rd
4th
5th
6th
T-shirt Size
*
Please Select...
YS
YM
YL
YXL
AS
AM
AL
AXL
Child 2 First Name
*
Child 2 Last Name
*
Child 2 D.O.B
*
MM slash DD slash YYYY
Child 2 M/F
*
M
F
Child 2 grade in september
*
k
1st
2nd
3rd
4th
5th
6th
T-shirt Size
*
Please Select...
YS
YM
YL
YXL
AS
AM
AL
AXL
Child 3 First Name
*
Child 3 Last Name
*
Child 3 D.O.B
*
MM slash DD slash YYYY
Child 3 M/F
*
M
F
Child 3 grade in september
*
k
1st
2nd
3rd
4th
5th
6th
T-shirt Size
*
Please Select...
YS
YM
YL
YXL
AS
AM
AL
AXL
Child 4 First Name
*
Child 4 Last Name
*
Child 4 D.O.B
*
MM slash DD slash YYYY
Child 4 M/F
*
M
F
Child 4 grade in september
*
k
1st
2nd
3rd
4th
5th
6th
T-shirt Size
*
Please Select...
YS
YM
YL
YXL
AS
AM
AL
AXL
Child 5 First Name
*
Child 5 Last Name
*
Child 5 D.O.B
*
MM slash DD slash YYYY
Child 5 M/F
*
M
F
Child 5 grade in september
*
k
1st
2nd
3rd
4th
5th
6th
T-shirt Size
*
Please Select...
YS
YM
YL
YXL
AS
AM
AL
AXL
Child 6 First Name
*
Child 6 Last Name
*
Child 6 D.O.B
*
MM slash DD slash YYYY
Child 6 M/F
*
M
F
Child 6 grade in september
*
k
1st
2nd
3rd
4th
5th
6th
T-shirt Size
*
Please Select...
YS
YM
YL
YXL
AS
AM
AL
AXL
Hidden
Junior counselor First Name
*
Hidden
Junior counselor Last Name
*
Hidden
Junior counselor D.O.B
*
MM slash DD slash YYYY
Hidden
Junior counselor M/F
*
M
F
Hidden
Junior counselor grade in september
*
7th
8th
9th
10th
11th
12th
Hidden
T-shirt Size
*
Please Select...
YS
YM
YL
YXL
AS
AM
AL
AXL
1st Junior counselor First Name
*
1st Junior counselor D.O.B
*
MM slash DD slash YYYY
1st Junior counselor M/F
*
M
F
1st Junior counselor grade in september
*
7th
8th
9th
10th
11th
12th
1st T-shirt Size
*
Please Select...
YS
YM
YL
YXL
AS
AM
AL
AXL
2nd Junior counselor First Name
*
2nd Junior counselor D.O.B
*
MM slash DD slash YYYY
2nd Junior counselor M/F
*
M
F
2nd Junior counselor grade in september
*
7th
8th
9th
10th
11th
12th
2nd T-shirt Size
*
Please Select...
YS
YM
YL
YXL
AS
AM
AL
AXL
3rd Junior counselor First Name
*
3rd Junior counselor D.O.B
*
MM slash DD slash YYYY
3rd Junior counselor M/F
*
M
F
3rd Junior counselor grade in september
*
7th
8th
9th
10th
11th
12th
3rd T-shirt Size
*
Please Select...
YS
YM
YL
YXL
AS
AM
AL
AXL
4th Junior counselor First Name
*
4th Junior counselor D.O.B
*
MM slash DD slash YYYY
4th Junior counselor M/F
*
M
F
4th Junior counselor grade in september
*
7th
8th
9th
10th
11th
12th
4th T-shirt Size
*
Please Select...
YS
YM
YL
YXL
AS
AM
AL
AXL
5th Junior counselor First Name
*
5th Junior counselor D.O.B
*
MM slash DD slash YYYY
5th Junior counselor M/F
*
M
F
5th Junior counselor grade in september
*
7th
8th
9th
10th
11th
12th
5th T-shirt Size
*
Please Select...
YS
YM
YL
YXL
AS
AM
AL
AXL
Parent(s)/Guardian Information
Parent/Guardian Name
*
Address
*
Phone:(H)
*
(C)
*
Email
*
Phone to be contacted during VBS:
*
Emergency Contact other than Parent/Guardian(listed above):
*
Person who will pickup child (will need ID)
Name
*
Phone
*
Name
Phone
Additional Information
(Please indicate child’s name next to Special Consideration and Allergies)
Special Considerations:
Allergies:
Faith Formation takes photographs of children during the week to be used in slide show and/or parish website.
I DO give permission for my child’s likeness/name to be included.
I DO NOT give permission for my child’s likeness/name to be included.
Signature of Parent/Guardian
Date:
MM slash DD slash YYYY
1 Student Fee
Price:
2 or 2+ Siblings Fee
Price:
0x Junior counselor Fee
Price:
1x Junior counselor Fee
Price:
2x Junior counselor Fee
Price:
3x Junior counselor Fee
Price:
4x Junior counselor Fee
Price:
5x Junior counselor Fee
Price:
6x Junior counselor Fee
Price:
7x Junior counselor Fee
Price:
Total
$0.00
* Full payment of fee is required when you submit this Registration Form. Please proceed to the next page for payment information and complete the registration. If you are unable to pay now, please contact the Faith Formation Office.
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