Grace's Diner 2026 VBS Registration Form

Child #1 Name

Child #1 Age

Child #2 Name

Child #2 Age

Child #3 Name

Child #3 Age

Child #4 Name

Child #4 Age

Child #5 Age

Parent/Guardian Name(s)

This address will receive a confirmation email

Phone

Address

Do(es) any child(ren) have any medications, food allergies, or medical needs?

Yes (Please explain below.) No

Please note any Medications/Food Allergies/Medical Needs, etc.

Optional, Secure Tax-Deductible Donation

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

Saturday, July 18, 2026 (9AM–3PM)

Please fill out this form and click submit.