Awana Registration Form

Participant's Names & Ages:

Example: John (Age 7), Elizabeth (Age 5), etc.

Parent/Guardian's Name:

Address

City, State, ZIP

Home Phone

Work Phone

Cell Phone

Email

Emergency Contact

Name and Phone #

People (other than parents) authorized to pick up children

Participant's Birthdate

Participant's Gender

Participant's Grade

Participant's School

Medical Information

Please include Child's primary physician's name and phone number. Also, be sure to list any allergies, medicines, special needs, etc.

Terms and Conditions

1) I understand that my child/children may participate in activities such as those held during game time. As with any physical activity, there is a risk of injury. I fully accept this risk and hold harmless from any legal liability Immanuel Baptist Church and any persons involved in the Awana Club ministry. 2) In the event of an emergency that requires medical treatment of the above named child/children, I understand every effort will be made to contact me or my emergency contact. However, if I/we cannot be reached, I do hereby consent to any hospital, medical or surgical care and treatment, and the administration of anesthesia, determined by a qualified physician to be necessary for my child's well being while under the custody and control of Immanuel Baptist Church personnel. I assume responsibility for all costs connected to any accident or treatment of my child. 3) I grant permission for photos of my child/children to appear among other general club photos that will be taken throughout the club year. 4) I grant permission for my child to be transported by the church or private vehicle to/from Awana Club events held during the 2016-2017 Awana Club Year. Any such event will be clearly communicated with me beforehand and will comply with the IBC Child Protection Policy.

Parent Signature

Please type your name below as an electronic signature confirming that all information provided is accurate and complete.

Photo Consent:

May we use photos of the above child/children for promotional purposes related to Immanuel Baptist Church?