Student Registration Form

Student Registration Form

Please fill out one form for each child registering for Education Programs at Cornerstone United Methodist Church.
Student's Name

First NameLast Name
Gender
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Age
Grade Entering Fall of 2022
Parent(s) or Guardian(s)
Siblings
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
Email
example@example.com
Who else, besides parent(s) or guardian(s), can pick up my child from church
In Case of Emergency
Emergency Contact Person (if parents are not available)
Relationship to student
Emergency Phone

Area CodePhone Number
Current Medications
Any Medical Conditions, Special Needs or Allergies
Authorization by Parent/Guardian: I hereby give my permission for my child to participate in Cornerstone UMC activities and I consent that CUMC may use any pictures or videos that my child appears in for promotional purposes. I also authorize delivery of necessary emergency care by available medical personnel as needed.
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty: