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Aside AWANA Registration Awanas Registration If you are human, leave this field blank. Registration/Medical Release Form (For club meetings and all supervised Awana outings) Bethel Baptist Church, Fredericksburg, VA (540) 371-3650 Club Cubbies (3-4 yrs) K-Sparks 1st-2nd Sparks T&T Girls (3rd-5th) T&T Boys (3rd-5th) Is this a transfer from another church? Yes No Name of church transferring from (Please provide proof of completed books.) Clubber's Legal Name First, Middle, Last Nickname Gender * M F 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 Father Guardian Father's Name: First, Last Father's Home Phone * Father's Cell Phone Father LIVING WITH CLUBBER? Yes No Mother Mother Guardian Mother's Name: First, Last Mother's Home Phone Mother's Cell Phone Mother LIVING WITH CLUBBER? Yes No 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:
