Mount Olivet UMC VBS - ROAR
Registration Form
Email address *
Child's Name *
Your answer
Child's Birth Date *
MM
/
DD
/
YYYY
Grade Entering Upcoming School Year *
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Parent/Guardian's Name *
Your answer
Parent/Guardian's Cell Phone Number *
Your answer
Emergency Contact Person *
Your answer
Emergency Contact Person Phone Number *
Your answer
Known Allergies *
Health Insurance Company/Policy # *
Your answer
Does your child have any special or medical needs? *
Your answer
I grant Mount Olivet UMC permission to use photographs of my child for informational or promotional purposes on its website or social media accounts. *
I, the undersigned parent/guardian of the above listed child(ren), a minor, do hereby authorize adult volunteers of Mount Olivet UMC's VBS Program as agent(s) for the undersigned, to consent to any medical or surgical care deemed advisable by any accredited physician or surgeon in an approved emergency clinic or hospital. I further release from any liability Mount Olivet UMC and any of its ministries or leaders in the event of an accident en route, during and returning from the above mentioned event. This agreement does not apply to claims for intentional misconduct or gross negligence. *
By entering your name below, you are effectively signing this form granting the above permissions. *
Your answer
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