First Name

Last Name

Date of Birth

School Grade

Email Address

Parent/Guardian Email:

Mailing Address

Mailing City

Mailing State

Mailing Zip Code

Dietary Restrictions NoneGluten-FreeDairy-FreePeanut Allergy

Mental Health NoneADHDAnxiety/DepressionOther

I understand that my child will not be registered until I pay the $85 NON-REFUNDABLE deposit to Countryside Covenant Church