CHBC Student Registration

CHBC Student Registration

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

Kingdom Kids Bible Club4:12 Youth
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?*

Current School YearNext School Year
Does Student Attend Church?

YESNO
Permission to Photograph Student?*

YESNO
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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