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Bethel Baptist Church

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AWANA Registration

Awanas Registration

Registration/Medical Release Form

(For club meetings and all supervised Awana outings)

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

First, Middle, Last
Number & Street, City, Zip Code
P.O. Box or Street, City, Zip Code

PARENT / GUARDIAN / FAMILY INFORMATION

First, Last

First, Last

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.

Sending