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 Name Last Name
Gender

Male Female
Birthdate *

Month Day Year
Age *
Grade Entering Fall of 2022
Parent(s) or Guardian(s) *
Siblings
Mailing Address *

Street Address

Street Address Line 2

City State

Zip Code
Primary Phone Number *

Area Code Phone Number
Secondary Phone Number

Area Code Phone 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 Code Phone 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 *

Month Day Year
Should be Empty: