1. Youth/Child's Name:
Child Age And Grade:
Child Birthday:
Child School:
List and allergies your children may have to food, medicines:
List of special needs your child(ren) may need:
Parents'/Guardians' Names*:
Home Phone:
Work Phone:
Address:
Special Delivery Instructions:
Email*:
Emergency Contact Name:
Emergency Contact Number:
Church Affiliation:
Parents permission for photographed/video taped/posted online?:YesNo
Comments related to LOGOS program:
I authorize LOGOS program personnel to take my child to the hospital in case of a medical emergency.