Mount Olive Kids Registration Form

Child's Name:*
Child's Grade:*
Child's Age:*
Child's Street Address:*
Child's City, State & Zip*
Child's Birth Date*
Parent's E-mail Address*
Mother's Name:*
Mother's Phone Number:*
Father's Name:*
Father's Phone Number:*
Emergency Contact in the event Parent's cannot be reached:*
Emergency Contact Phone Number:*
Important Medical Information (asthma, food allergies, diabetes, etc.)*
Image Release Consent: As part of our ministry, we take photographs and videos of people in action as they participate in Mount Olive events. We reserve the right to use these images for non-profit purposes. By selecting yes, you authorize the use of any image of yourself and/or your children.*
Emergency Release Information: If I cannot be reached, I authorize Mount Olive staff to drive to the physician, dentist, or hospital. Ambulance may be called if necessary.*
Name of Parent authorizing Emergency Release Information:*


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