Cornerstone Christian School Registration Form

Cornerstone Christian School

REGISTRATION FORM
STUDENT INFORMATION
Name

First NameMiddle NameLast NameSuffix
Student's Date of Birth
Student's Gender
Student Resides With
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Marital Status
Parent Responsible for Tuition
PARENT INFORMATION
Father's Name

First NameLast Name
Father's Address (if different from student's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Cell Phone Provider (required for text alerts)
Work Phone
Please enter a valid phone number.
Employer
Mother's Name

First NameLast Name
Mother's Address (if different from student's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Cell Phone Provider (required for text alerts)
Work Phone
Please enter a valid phone number.
Employer

ADDITIONAL STUDENT INFORMATION
Will your child be attending Extended Day Care (EDC)?
Name and Grade Level of any sibling(s) attending Cornerstone:

MEDICAL INFORMATION
Family Doctor's Name

First NameLast Name
Doctor's Contact Number
Please enter a valid phone number.
Insurance Company
Insurance ID #
Member's Name
Please list any chronic conditions or allergies.
Please list any medications and frequency.
A "STUDENT MEDICAL AUTHORIZATION FORM" MUST BE COMPLETED AND SIGNED BY THE CHILD'S PHYSICIAN BEFORE ANY MEDICATION (PRESCRIBED OR OTC) CAN BE ADMINISTERED TO THE STUDENT AT SCHOOL.
Does the student wear glasses?

AUTHORIZED PERSONS FOR PICK-UP AND EMERGENCY CONTACT

(OTHER THAN PARENT)
Name

First NameLast Name
Type of Authorization
Relationship to Student
Daytime Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Type of Authorization
Relationship to Student
Daytime Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Type of Authorization
Relationship to Student
Daytime Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Type of Authorization
Relationship to Student
Daytime Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Type of Authorization
Relationship to Student
Daytime Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Type of Authorization
Relationship to Student
Daytime Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Type of Authorization
Relationship to Student
Daytime Phone Number
Please enter a valid phone number.
AUTHORIZED PERSONS MUST BE 18 YEARS OF AGE AND SHOULD BE PREPARED TO SHOW A VALID PICTURE ID WHEN PICKING UP STUDENTS. STUDENTS WILL NOT BE RELEASED TO ANYONE WHO IS NOT NAMED ABOVE. PLEASE NOTIFY THE OFFICE, IN WRITING, IMMEDIATELY WITH ANY CHANGES TO THIS LIST. EMERGENCY CONTACTS WILL BE CALLED FOR URGENT SITUATIONS WHEN THE STUDENT'S PARENTS ARE UNABLE TO BE REACHED.

PERSONS DENIED STUDENT PICK-UP

A CURRENT JUDGEMENT AND/OR COURT ORDER OF PROTECTION IS REQUIRED AND MUST BE ON FILE AT THE SCHOOL OFFICE
Full Name

First NameLast Name
Relationship to Student
Full Name

First NameLast Name
Relationship to Student

- Cornerstone Christian School admits students of any race, color, nationality and ethnic origin to all of the rights, privileges, programs and activities generally accorded or made available to the students of the school. It does not discriminate on the basis of color, nationality or ethnic origin in the administration of its admissions, education, athletics or any other school program.
- Cornerstone Christian School will not be responsible for lost, damaged, or stolen property brought to school by any student.
- Cornerstone Christian School is not liable for any fraudulent misrepresentation of the school.
- Students enrolled and attending Cornerstone Christian School are covered under the group insurance plan in the event of any injury sustained by the student at school or a school-sponsored activity during the school year.
Statement of Cooperation:
I/We give permission for Cornerstone Christian School (hereafter named "the School") to contact previous schools my child has attended for academic and medical information that may include recommendations, screenings, and/or placement in any special service or special education program.

I/We agree to follow the policies set by the School and published in the Parent-Student Handbook.

I/We understand that a written submission must be received by the Administration before a student is considered officially withdrawn from enrollment for any reason.

I/We understand that the Administration may determine to suspend or expel a student at any time, depending on the seriousness of the situation.

I/We understand that I/we are liable for any and all damages to the School's property and/or equipment caused by my child and will be asked to many any subsequent restitution.

I/We give permission for my/our child to take part in all School activities or field trips, including those that are held off-campus and require transportation by bus or van, and agree to relieve the School, its employees and/or its agents of any liability in connection with these activities.

I/We agree to hold the School and its employees harmless and/or agents harmless for any liability to my cihld, or any parent or guardian thereof, due to any claims on behalf of my child against the School, any employee and/or agent thereof because of any injury or alleged injury to my child. Should there be any legal action taken, for any reason, against the School, any employee and/or agent thereof, and said party/parties are not found at fault, I/we agree to pay any attorney fees, court costs, and/or other such expenses that the School, its employees and/or its agents thereof should incur to defend itself against such action.

I/We understand that this "Statement of Cooperation" will be in effect for as long as my child attends Cornerstone Christian School.
Signature

Clear
Date

MonthDayYear
Date

Documents

Please upload the following documents. For double-sided documents, please ensure both sides are scanned and uploaded. If you choose not to upload your documents, they must be submitted, in person, to the school's Main Office within 1 week of submission of registration. Please ensure all documents are dated, signed and complete.
Please upload the following documents: Birth Certificate, Current Immunizations & Physical (on State of Illinois form)

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Additional paperwork is required for Preschool and Kindergarten students. Please schedule an appointment to come in and complete the required documents.
Should be Empty:

Cornerstone Christian School

STUDENT INFORMATION

PARENT INFORMATION

ADDITIONAL STUDENT INFORMATION

MEDICAL INFORMATION

AUTHORIZED PERSONS FOR PICK-UP AND EMERGENCY CONTACT

PERSONS DENIED STUDENT PICK-UP

Statement of Cooperation:

Documents