Awana Registration | Bethel Baptist Church

Registration/Medical Release Form

(For club meetings and all supervised Awana outings)

Bethel Baptist Church, Fredericksburg, VA (540) 371-3650

Club

Is this a transfer from another church?

Yes

Name of church transferring from (Please provide proof of completed books.)

Clubber's Legal Name

First, Middle, Last

Nickname

Gender *

Date of Birth

Age:

Grade:

School:

Family Church:

Clubber's email:

Home Phone:

Parent's email:

Home Address:

Number & Street, City, Zip Code

Mailing Address (if different):

P.O. Box or Street, City, Zip Code

PARENT / GUARDIAN / FAMILY INFORMATION

Father

Guardian

Father's Name:

First, Last

Father's Home Phone *

Father's Cell Phone

Father LIVING WITH CLUBBER?

Yes

Mother

Guardian

Mother's Name:

First, Last

Mother's Home Phone

Mother's Cell Phone

Mother LIVING WITH CLUBBER?

Yes

Emergency Contact Information:

In case I/we cannot be reached during an emergency, I/we the undersigned give permission for my/our child to be treated by a a licensed physician if this emergency might endanger his/her life and/or cause disfigurement, physical impairment or undue discomfort by delaying treatment. Said physician is to administer whatever care is necessary, including anesthesia.

The undersigned assumes responsibility for any costs connected with such treatment and hereby releases Awana Clubs International, Bethel Baptist Church of Fredericksburg, Virginia and the driver of any vehicle transporting my child to a supervised Awana outing, from liability.

This release form is completed and signed of my/our own free will and with the sole purpose of authorizing medical treatment under emergency circumstances in my/our absence.

Emergency Contact #1 Name:

Emergency Contact #1 Relationship:

Emergency Contact #1 Phone Number:

Emergency Contact #2 Name:

Emergency Contact #2 Relationship:

Emergency Contact #2 Phone Number:

If you are human, leave this field blank.