Logos Registration

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.