Madison Street United Methodist Church

319 Madison Street, P.O. Box 864 ~ Clarksville, Tennessee ~ 37041-0864
Office (931) 647-0221 ~  Fax (931) 551-8913

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2009 VBS Registration - Madison Street United Methodist Church
**Please complete a separate form for each child**

Name of Child     

Date of Birth       

Street Address   

City, State, Zip   

Home Church     

Grade Completed in May 2009   

Allergies or other concerns:
                                                                                           

Parent Name          

Home Phone       

Parent Location during VBS   

Emergency Contact Name     

Emergency Contact Number  

Person who may pick up child: 

I can help with VBS:   yes    no

The costs listed below are for 5 nights of dinners, Sunday through Thursday.
  (For assistance with meal costs, please call Gracie 647-0221). 
Dinner will be served at 5:30 in the fellowship hall. 

1 person-$10    2 people-$20      3 people-$30      4 or more-$40

Please indicate below the number of people eating each night:

Children Meals:

Adult Meals:

Meal reservations and payment must be received by July 5 in the office OR put this
form and your payment in an envelope in the collection plate on Sunday morning.