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Backyard Bible School Registration
For questions call: (815)672-2460
(Group sizes are limited to 12 in each group)
See information flyer on Events page for locations and groups
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Indicates required field
Choose One
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Location 1
Location 2
Location 3
Choose One
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Group 1
Group 2
Group 3
Group 4
Group 5
Group 6
Child's Name
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First
Last
Birthday
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mm/dd/yyyy
Grade Completed
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Age
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Parent/Guardian Name
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First
Last
Phone Number
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Home Address
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Line 1
Line 2
City
State
Zip Code
Country
Emergency Contact
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Relationship to Student
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Emergency Contact Phone Number
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Food Allergies
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Yes
No
If yes, list;
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Medical Concerns
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Yes
No
If yes, explain;
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If you attend a church, where?
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Person(s) Name(s) Who May Pick up the Child
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First
Last
Phone Number
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Name
*
First
Last
Phone Number
*
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Home
I’m New
About
Ministries
Ministries
Missions
Sermons
Calendar
Giving
Contact