REGISTER NOW for Cornerstone Church Cheshire's SUMMER BLAST for kids ages 6-12
Registration Form - ****PLEASE COMPLETE ONE FORM FOR EACH CHILD

SUMMER BLAST is August 12, 13, 14 from 9:00 AM - 12:30 PM @ Cornerstone Church, 1146 Waterbury Rd., Cheshire

Email address *
Child's First Name *
Your answer
Child's Last Name *
Your answer
Parent/Guardian Name *
Your answer
Street Address *
Your answer
City *
Your answer
Zip *
Your answer
Mailing Address (if different) Street, City, Zip
Your answer
Home Phone Number *
Your answer
Cell Phone Number *
Your answer
Age Information *
MM
/
DD
/
YYYY
Last grade completed in school *
Your answer
MEDICAL INFO / ALLERGY INFO
Medical Information-Please list medical information we need to know & any ALLERGIES below. *
Your answer
Emergency Contact #1: Name & Phone number *
Your answer
Emergency Contact #2: Name & Phone number *
Your answer
Dismissal Information-Please name who may pick up your child at the end of Summer Blast *
Your answer
Other Information: (Please check if "yes")
If visiting, who are you a guest of?
Name?
Your answer
Any additional information we need to know?
Your answer
A copy of your responses will be emailed to the address you provided.
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