Olympian Clubs 2019-20
Parent/Guardian Last Name:
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Parent/Guardian First Name:
*
Street Address:
*
City:
*
State:
*
Zip:
*
Home Phone:
Work Phone:
Cell Phone:
Your Email Address
*
Church You Regularly Attend:
Previous Children's clubs where children have completed work & awards received:
First Child's Name:
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Number of children you are registering for Gopher club (4-K) and/or Olympian Club (1-6 grades)
One Child
Two Children (Add $30.00)
Three Children (Add $60.00)
Four Children (Add $90.00)
Five Children (Add $120.00)
DOB:
*
Grade:
*
Gender:
*
Male
Female
Medical conditions or allergies we should be aware of:
Age Group:
*
Gopher (4-K)
Challenger (1-2 grades)
Conqueror (3-4 grades)
Champion (5-6 grades)
Second Child's Name:
DOB:
Grade:
Gender
*
Male
Female
Medical conditions or allergies we should be aware of:
Age Group:
*
Gopher (4-K)
Challenger (1-2 grades)
Conqueror (3-4 grades)
Champion (5-6 grades)
Third Child's Name:
DOB:
Grade:
Gender:
*
Male
Female
Medical conditions or allergies we should be aware of:
Age Group:
*
Gopher (4-K)
Challenger (1-2 grades)
Conqueror (3-4 grades)
Champion (5-6 grades)
Fourth Child's Name:
DOB:
Grade:
Gender:
*
Male
Female
Medical conditions or allergies we should be aware of:
Age Group:
*
Gopher (4-K)
Challenger (1-2 grades)
Conqueror (3-4 grades)
Champion (5-6 grades)
Fifth Child's Name:
DOB:
Grade:
Gender:
*
Male
Female
Medical conditions or allergies we should be aware of:
Age Group:
*
Gopher (4-K)
Challenger (1-2 grades)
Conqueror (3-4 grades)
Champion (5-6 grades)
Emergency Contact/Medical Release:
In case of an emergency, I may be reached at (Phone):
Contact the following person if I cannot be reached: Name:
Relationship to child:
Address:
Phone:
Second emergency contact: Name:
Relationship to child:
Address:
Phone:
Do you give permission for FBCGE leadership to administer medical treatment in an emergency after attempts to contact you have been made?
*
Yes
No
Your preferred physician is Dr.:
Phone:
Your preferred dentist is Dr.:
Phone:
Preferred hospital if transfer is needed:
Photographs and video are occasionally taken during club meetings. Do you give permission for FBCGE to display photographs or video of your child(ren) for promotional use?
*
Yes
No
Liability Release: I grant permission for my child(ren) to participate in all activities of the Olympian program sponsored by FBCGE of Batavia, OH.
My permission releases the church, its leaders and workers from any responsibility for an injury that may occur during the course of the nightly meeting or special activities.
Your Full Name (signature):
Date:
Please type
in the box to the right »
*
Base Price
$
Modifications
$
Total
$
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