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SAINT NICHOLAS HELLENIC ORTHODOX PRIMARY EDUCATION  (H.O.P.E.)
(Under the advisement and spiritual guidance of Rev. Father Nicolaos H. Kotsis)

Our forms are in Adobe Acrobat® PDF format.  If you need the Acrobat reader, click here. 
To print the PDF of both the Registration and Health forms version CLICK HERE
To print the PDF of the Registration form version CLICK HERE  |  To print the PDF of the Health form version CLICK HERE

2008 – 2009 REGISTRATION and PERMISSION SLIP / HEALTH and MEDICAL FORM
The parent/legal guardian of the child/children who are registered to attend these activities in order that the appropriate care is given if and when needed must complete this health form for your child/children to participate in this activity and MUST inform us of any changes immediately.

My (our) son/daughter:  _____________________________________________    Birth Date:  ______________________
                                     (Please fill out a separate form for each child)

Address: _____________________________________________________________________   Gender (  ) Male (  ) Female
                   Street                                 City                                         State             ZIP

has my permission to attend and participate in the _________________________________________________  (Activity)

to be held at  ___________________________________  at/in  _____________________________________
                                  (Location)                                                                    (Location)

from  ________________________________________  to  ________________________________________
                                  (Start Date)                                                                 (End Date)

for the purpose of  _____________________________________________________________________

I (we) understand that it is not the responsibility of Saint Nicholas Greek Orthodox Church of Ann Arbor to provide transportation to or from this activity and hold harmless the Saint Nicholas Greek Orthodox Church of Ann Arbor, Michigan, its Priest, Parish Council, Officers, Advisors and Chaperones for any and all harm or injury that may occur to my above named child while traveling to and from and attending and participating in the above mentioned event. I (we) release Saint Nicholas Greek Orthodox Church and its agents from any liability for any accident, injury, or loss of property of my (our) child.  I further state that my (our) above named child shall follow the directions and advice of the advisors and chaperones accordingly while traveling to and from and while attending and participating in the above named event.

PLEASE NOTE:  We expect our ___________________ members to respect one another, our host (s) and their property at this function.  In addition, to behave in accordance to the rules set by the host, chaperones, advisors, and Saint Nicholas otherwise they will be required to phone parents to pick up their child and take them home.

Name of parent/legal guardian (s):  _____________________________________________________________  (Please Print)

Signature of parent/legal guardian: _______________________________________ Date: _________________

Address (if different from above): __________________________________________________________________________
                                                         Street                                   City                                      State               ZIP

Father:   Daytime Phone (____)  ____ - _____    Evening Phone (____)  ____ - ______    Cell Phone (____)  ____ - ____

Mother:  Daytime Phone (____)  ____ - _____    Evening Phone (____)  ____ - ______    Cell Phone (____)  ____ - ____

E-Mail Address (list all):  ____________________________________________________________________

I (we) also give permission for my (our) son/daughter to ride in a vehicle driven by an adult chaperone (18 years of age and over) pre-approved by the Saint Nicholas Greek Orthodox Church Parish Council and Rev. Father Nicolaos H. Kotsis.

Signed (Father):  ________________________________      Signed (Mother):  __________________________________

Suggested Donation Registration is $35 per Family

__________  Cash    __________  Check    (Please make your check payable to Saint Nicholas G.O.Y.A.)

2008 – 2009 HEALTH and MEDICAL INFORMATION FORM
The parent/legal guardian of the child/children who are registered to attend these activities in order that the appropriate care is given if and when needed must complete this health form for your child/children to participate in this activity and MUST inform us of any changes immediately.

Childs Name:  _____________________________________________    Birth Date:  _____________________________

Address: ________________________________________________________________________   Gender: (  ) Male (  ) Female
                    Street                                             City                                   State           ZIP

Name of custodial parent/legal guardian(s):  ________________________________________________________ (Please Print)

Home Address:   ___________________________________________________________________________________
(If different from above)              Street Address                          City                              State                 ZIP

Father:   Daytime Phone (____)  ____ - _____    Evening Phone (____)  ____ - ______    Cell Phone (____)  ____ - ____

Mother:  Daytime Phone (____)  ____ - _____    Evening Phone (____)  ____ - ______    Cell Phone (____)  ____ - ____

If not available in an emergency, notify:  Name: __________________________________  Relationship: _____________

Address:  _____________________________________________________________________  Phone: (___)  ___ - ____
                    Street                                     City                              State                 ZIP

Insurance Information: Is the participant covered by family medical/hospital insurance?      Yes  (   )       No  (   )

If so, indicate carrier or plan name:  ______________________________    Group #  _________________________

Name and phone number of personal physician and practice:  _____________________________________________________

I (we) give permission for above named minor to receive any emergency treatment (medical or surgical) and to receive basic medication or first aid from the adults on the trip.  I (we) will assume responsibility for any such medical expenses incurred.
The adults may administer:        _____ Aspirin     _____ Tylenol      _____ Ibuprofen

Medication:  Please list and indicate any medications your child must take during the time of this treatment, if any.

        This minor takes no medications on a routine basis or none that needs to be taken during the duration of the activity

        This person takes medications as follows (list names and dosages):

Medication #1:  _________________________ Dosage____________________ Specific times each day _____________

Describe reaction (s) and management of the reaction and reason for taking: __________________________________________________________________________________________________

Medication #2:  _________________________ Dosage____________________ Specific times each day _____________

Describe reaction (s) and management of the reaction and reason for taking: __________________________________________________________________________________________________

Medication Allergies                                                              Food allergies (list all known)
#1  __________________________________________              ________________________________________________

#2  __________________________________________              ________________________________________________

My (our) child has been vaccinated for:  __________________    tetanus (give date of last booster)  _________________

List any dietary or physical restrictions, or other medical conditions (check where applicable) your child may have:
_______________________________________________________________________________________________

___ rheumatic fever ___ asthma ___ diabetes ___ motion sickness ___ heart problems ___ seizure disorder ___ urinary tract difficulty

____ difficulty getting along with peers or authority figures (explain): _________________________________________

____ other problems leading to unconsciousness (explain): __________________________________________________

Our forms are in Adobe Acrobat® PDF format.  If you need the Acrobat reader, click here. 
To print the PDF of both the Registration and Health forms version CLICK HERE
To print the PDF of the Registration form version CLICK HERE  |  To print the PDF of the Health form version CLICK HERE

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