CHILD PERSONAL INFORMATION Child`s First Name Child`s Last Name Sex M F Birthday Month January February March April May June July August September October November December Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Grade just completed Pre-School Kindergarten !st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade FOOD ALLERGIES and-or MEDICAL CONDITIONS WE NEED TO KNOW ABOUT! Does your family attend church? If so, where? Yes No My child will be eating supper at VBS. Yes No I give permission for Cornerstone to photograph my child for Security Purposes and Internal Use only (Internal Use = Record Keeping, Church Bulletin Boards, Sunday Morning Slideshows).
CHILD`S CURRENT ADDRESS Street Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip
PARENT INFORMATION PARENT/GUARDIAN First Name Last Name Contact Phone Numbers - Primary Secondary Email Emergency Contact 1 - Name Phone Emergency Contact 2 - Name Phone DISMISSAL INFORMATION
Signature
