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

MaleFemale
Birthdate*

MonthDayYear
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
Should be Empty: