CedarBend Church - Student Registration

Student Details

First Name

Last Name

Phone Number

Date of birth

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Grade for the '23/'24 School Year

Gender

Emergency Contact Details

In the event of an emergency relating to your son/daughter please provide information below which we can use to contact you.

First Name

Last Name

Email

Phone Number

Medical Information

Are there any medical conditions (i.e. allergies, epilepsy, asthma, diabetes, travel sickness, etc.) which we should be aware of?

Medical Information

Please give any details of special dietary needs we should be aware of (e.g. food allergies)

Dietary Restrictions

I, the parent or guardian, give the student permission to attend and participate in this activity. I understand that care will be taken to ensure the health, safety, and welfare of my child. I realize and accept that in the event of my child’s behavior adversely affecting the safety of the activity, the organizers reserve the right to return my child home.

Signature

Date