Do You Have Children (Age 4 Through 6th Grade ?): You Can Sign Up Right Now !
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Please fill in the information below and click the "Submit" button
below the Medical Release form
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(1) Name
Age
Grade Completed
(2) Name
Age
Grade Completed
(3) Name
Age
Grade Completed
(3) Name
Age
Grade Completed
Address
Regularly Attend Church?
Yes
:
No :
Occasionally:
If Yes, Where do you attend ?
Parent(s) / Guardian (s)
Home Phone Number
Cell or Work Number
Emergency Contact (other than parent)
Emergency Contact Phone Number
How did you hear about Olympion VBS this year?
Newspaper Article
Radio Advertising
Web Site
Flyer / Poster
A Friend
Word of Mouth
Attended Last Year
email address:
Do you have any specific questions or concerns for us ?
Medical Release Form
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Please fill out each line as applicable for you children
Name of family doctor or physician most visited :
Physician's Phone Number :
Known conditions, allergies or additional helpful information for:
please enter the name of the first child listed above.
are as follows:
Please fill out here... If none, please write None. Do not leave blank.
Known conditions, allergies or additional helpful information for:
please enter the name of your second child listed above.
are as follows:
Please fill out here... If none, please write None. Do not leave blank.
Known conditions, allergies or additional helpful information for:
please enter the name of your third child listed above.
are as follows:
Please fill out here... If none, please write None. Do not leave blank.
Known conditions, allergies or additional helpful information for:
please enter the name of the fourth child listed above.
are as follows:
Please fill out here... If none, please write None. Do not leave blank.
In case of medical emergency, I hereby give my permission to the Olympion Director to secure proper treatment for my child using her best judgment including the selection of a physician and / or hospitalization for the following
child or children:
Note: The Olympion Director will make every attempt to contact the parent / legal guardian listed or the emergency contact listed on the above registration form.
I Agree With Above:
I Don't Agree With the Above:
Signature of Parent or Legal Guardian :
