Olympian Registration 2011-2012

Name:
Age: Birthdate: Grade:
Address:
School:
Home Phone:
Parent or Guardian Business or Cell Phone:

Additional Children of the same household:

Name:
Age: Birthdate: Grade:

Name:
Age: Birthdate: Grade:

Name:
Age: Birthdate: Grade:

The undersigned shall be and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs. The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by the Alfred Almond Bible Church.

Adult Granting Permission:
              Relationship to Child(ren): Father Mother Legal Guardian

I grant permission for my child's image to be included in Olympian Club photo's posted on the church's website (Please check one):
Yes No

Please note: Regular announcements and emergency cancellations will be sent out by e-mail and posted on the church website. If you do not have internet access we will contact you by phone for emergency cancellations.

Email Address:
                          I do not have internet access
                          Please notify me of cancellations at:

Additional Comments