2026 Halloween Bash Family Registration Form

Halloween Bash 2026 10am to 1pm FLIPSIDE Church 10912 Jersey Blvd. Rancho Cucamonga 91730 | Please fill out this form and click submit.

Name

*

Name-2

Phone

*

texts allowed

Phone #2

Address

*

Email

*

This address will receive a confirmation email

1-Name of Sick Child/Person

*

1-Age

*

1-B/G

*

Please select one option.

Boy Girl

1-DOB

*

Month & Year Diagnosed

*

Name of Cancer

*

Current Treatments. Please update us as to current treatments. If none-say none. Sees the dr. how many times a week or month. This will go into your chart. Thank you

*

Other Minor Kids 1st Name Only

2-Child

2-Age

2 -B/G

Please select one option.

Boy Girl

2-DOB

3-Child

3-Age

3-B/G

Please select one option.

Boy Girl

3-DOB

4-Child

4-Age

4-B/G

Please select one option.

Boy Girl

4- DOB

5-Child

5-Age

5-B/G

Please select one option.

Boy Girl

5-DOB

6-Child

6-Age

6-B/G

Please select all that apply.

Boy Girl

6-DOB

7-Child

7-Age

7-B/G

Please select all that apply.

Boy Girl

7-DOB

8 Child

8-Age

8-B/G

Please select one option.

Boy Girl

8-DOB

9-Child

9-Age

9-B/G

Please select one option.

Boy Girl

9-DOB

10-Child

10-Age

10-B/G

Please select one option.

Boy Girl

10-DOB

Emergency Contact Person

*

Cell Phone

*

Date

*

I /We do hereby release my/our story and my/our picture(s) to ADONAI, Inc. to be used to promote the success stories of ADONAI, Inc., its services and the successful support it provides to families in our community. Pictures & stories may be used in posters, newsletters, internet website, etc. I/We also acknowledge there shall be no financial or otherwise compensation paid, implied, guaranteed or suggested to you and/or your family, business or employer.

*

Description

Halloween Bash 2026 10am to 1pm FLIPSIDE Church 10912 Jersey Blvd. Rancho Cucamonga 91730

Please fill out this form and click submit.

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