Name
*
First Name
Last Name
Cell Number
*
E-mail
*
example@example.com
Are you a CMBC Member?
*
Yes
No
How many Adults Attending?
*
How many Children Attending?
*
Child 1 - Name
First Name
Last Name
Child 2 - Name
First Name
Last Name
Child 3 - Name
First Name
Last Name
Child 4 - Name
First Name
Last Name
Child 1 - Age
2-3 Years Old
4-5 Years Old
1st and 2nd Grade
3rd and 4th Grade
5th and 6th Grade
Junior High
High School
Child 2 - Age
2-3 Years Old
4-5 Years Old
1st and 2nd Grade
3rd and 4th Grade
5th and 6th Grade
Junior High
High School
Child 3 - Age
2-3 Years Old
4-5 Years Old
1st and 2nd Grade
3rd and 4th Grade
5th and 6th Grade
Junior High
High School
Child 4 - Age
2-3 Years Old
4-5 Years Old
1st and 2nd Grade
3rd and 4th Grade
5th and 6th Grade
Junior High
High School
Does the child 1 have any allergies, chronic illness, or medical conditions? If yes, please describe.
Does the child 2 have any allergies, chronic illness, or medical conditions? If yes, please describe.
Does the child 3 have any allergies, chronic illness, or medical conditions? If yes, please describe.
Does the child 4 have any allergies, chronic illness, or medical conditions? If yes, please describe.
Emergency Information
Emergency Contact's Name
*
First Name
Last Name
Relationship
*
Please Select
Mother
Father
Grandparent
Aunt
Uncle
Sibling
Babysitter/Nanny
Other
Phone Number
*
Alt. Phone Number
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