Forms

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

* Indicates required field

Choose One *

Location 1 Location 2 Location 3

Choose One *

Group 1 Group 2 Group 3 Group 4 Group 5 Group 6

Child's Name *

First

Last

Birthday *

mm/dd/yyyy

Grade Completed *

Age *

Parent/Guardian Name *

First

Last

Phone Number *

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Emergency Contact *

Relationship to Student *

Emergency Contact Phone Number *

Food Allergies *

Yes No

If yes, list; *

Medical Concerns *

Yes No

If yes, explain; *

If you attend a church, where? *

Person(s) Name(s) Who May Pick up the Child *

First

Last

Phone Number *

Name *

First

Last

Phone Number *

Submit