CHBC Student Registration

CHBC Student Registration

Cheatham Hill Baptist Church
Student Registration Form
CHBC Program (Check the one desired)
Student Full Name

First NameLast Name
Student Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Additional Phone

Area CodePhone Number
Grade in School
This Grade Current Year or Next?
Does Student Attend Church?
Permission to Photograph Student?
Student Birth Date (MM-DD-YYYY)
Parent or Guardian Full Name

First NameLast Name
Relationship to Student
Parent/Guardian Email
Authorized Person to Pickup Student

First NameLast Name
Phone Number

Area CodePhone Number
Authorized Person to Pickup Student

First NameLast Name
Phone Number

Area CodePhone Number
Authorized Person to Pickup Student

First NameLast Name
Phone Number

Area CodePhone Number
Authorized Person to Pickup Student

First NameLast Name
Phone Number

Area CodePhone Number
Emergency Contact Full Name

First NameLast Name
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact Phone

Area CodePhone Number
Emergency Contact - Alternate Phone

Area CodePhone Number
Student's Medical Issues
Allergies
Prescribed Meds (Please List)
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