LOGOS Online Registration and Medical Information

Please provide us with as much information as you can.  We appreciate the time you are taking to fill in this on-line form.  Thanks and have a nice day.  We hope to see you at LOGOS.

Date of Form       

Child 1

        Name:                                            

        Date of birth:                                      

        Grade:                                                 

        Food/Allergies or Concerns:              

Child 2

        Name:                                             

        Date of birth:                                      

        Grade:                                                 

        Food/Allergies or Concerns:               

Child 3

        Name:                                             

        Date of birth:                                      

        Grade:                                                  

        Food/Allergies or Concerns:               

Child 4

        Name:                                             

        Date of birth:                                      

        Grade:                                                 

        Food/Allergies or Concerns:               

Child 5

        Name:                                             

        Date of birth:                                      

        Grade:                                                  

        Food/Allergies or Concerns:               

Parents Name:                               

Mailing Address:

        Street 1                                   

        Street 2                                   

        City                                          

        Zip Code                                                   

        Home Phone                           

        Work Phone                             

        Cell Phone                                    

        E-mail Address                                         

Please provide the following emergency contact information:

        Name                                       

        Phone                                               

Church Affiliation:                          

Known Allergies, Medical or Health Concerns, Special Needs

(Information will be shared with those people working with your child)    

        Medical Problems                           

        Previous Surgeries                       

        Medications                                 

       Physician                                       

        Phone                                                      

        Dentist                                           

        Phone                                                

        Health Insurance Co.           

        Policy #                                            

        Members Social Security #       

In case Parent/Guardian cannot be reached please call:

#1

        Name                                   

        Relationship                                     

        Phone                                                           

        Cell Phone                            

#2

        Name                                   

        Relationship                                     

        Phone                                                           

        Cell Phone                            

After submitting your results, click this link to return to the Chat Room Link Page

Westminster Presbyterian Church Joliet, IL 60435
Copyright © 2003 [Westminster]. All rights reserved.
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