Event Form (select event below)

Illumination VBS 2026

Child's First name*

Child's Last name

Parent's Email*

Home Address

Emergency Contact Name/Relationship & Phone #

Child's Birthday

Month

Day

Year

Additional information/Allergies/Special Considerations for my child

Phone: (567) 712-7548

1606 W. Elm St.

Lima, OH 45805

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