Creative Arts Camp – VBS Summer 22 Step 1 of 2 50% VBS Registration for Children age 4 - 6th GradeChild's Name First Last Birth Date MM slash DD slash YYYY Age / Grade Entering* 4 Kindergarten 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade 7th grade Allergies or other health concerns:Learning disabilities or special needs / how can we help?Child's Name First Last Birth Date MM slash DD slash YYYY Age / Grade Entering 4 Kindergarten 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade 7th grade Allergies or other health concerns:Learning disabilities or special needs / how can we help?Child's Name First Last Birth Date MM slash DD slash YYYY Age / Grade Entering 4 Kindergarten 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade 7th grade Allergies or other health concerns:Learning disabilities or special needs / how can we help?Child's Name First Last Birth Date MM slash DD slash YYYY Age / Grade Entering 4 Kindergarten 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade 7th grade Allergies or other health concerns:Learning disabilities or special needs / how can we help? Please answer the following completely:1) Parent/Guardian Name(s)* First Last 2) Complete Mailing 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 3) Phone Number During VBS hours*4) Email Address* 5) Who will pick up your child/ren from VBS?* List all possible individuals who may pick up your child from VBS. 6) Phone number/s of person/s who will pick up your child from VBS* 6) Emergency Contact during VBS hours (name and phone#)* Can your child's picture appear on MPLC social media? (we never use names)* YES NO For more information, please contact Becky Litwin at blitwin@mplc.us or 262-634-6704.