Vacation Bible School Registration 2010
India Pentecostal Assembly 343 Jerusalem Ave, Hicksville, NY 11801 July 19-21, 2010 (9AM - 4PM)
Child's Full Name
Age
5
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14
Grade
Year Of Birth
Child's Full Name
Age
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14
Grade
Year Of Birth
Child's Full Name
Age
5
6
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8
9
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11
12
13
14
Grade
Year Of Birth
Child's Full Name
Age
5
6
7
8
9
10
11
12
13
14
Grade
Year Of Birth
Street
City
Zip Code
Phone Number (Home)
(Work)
(Cell)
E-Mail Address( To Confirm )
Emergency Contact Name
Relationship
Phone Number
Will You Be Bringing Your Child(ren)
Yes
No
If no, Name of Person
Phone Number
Any Allergy/Medication/ Special Care Instructions
Registration Fee of $10 Will be paid by
(If Cheque, Please Make Payable to PYPA and mail to George Samuel, 27 Beatrice Ave, Syosset, NY 11791)
Sending in a cheque-More Instructions In Email
Cash on Registration day
Indicates Response Required
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