Students Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home

(###)

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Cell

(###)

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Work

(###)

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Date of Birth

MM

DD

YYYY

Photo Release: St. Peter's Lutheran Church/VBS has my permission to use my child's photograph publicly in VBS materials. I understand that no royalty, fee or other compensation shall become payable to me by reason of such use.