Awana Registration Form

Awana 2009-2010 Registration

Parent/Guardian:	*
Phone Number	*
Address	*
City	*
Zip / Postal	*
State / Province	*

Email Address

Home Church:

Emergency Contact Name:	*
Phone Number:	*
Relationship to Child:	*
Family Physician:	*
Phone Number:	*

As Parents and/or guardian, I grant permission for my child to travel to/from Awana Club events with an adult leader. Any such event will be clearly communicated with me beforehand. I herewith authorize treatment under the direction of any licensed physician of the following minor(s) in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me by phone at the number(s) listed above. I assume the responsibility for any costs connected with such treatment and hereby releases the Brown Street Baptist Church of Madison County from any liability therefore.
Medical Consent	*	I agree I do not agree

I give my permission for my child’s picture to be used in the media of Brown Street Baptist Church as long as no personal information will accompany pictures. This includes, but is not limited to, church displays, flyers, and the church website: www.brownstreetbaptist.org.
Permission for Photos	*	I do I do not


Child's Name:	*
Birthday:	*
Grade:	*
Age:	*
Medical allergies or other conditions:

Child's Name:
Birthday:
Grade:
Age:
Medical allergies or other conditions