AWANA MEDICAL RELEASE

AWANA Registration & Medical Release Form

2024-2025
FAMILY LAST NAME*
Child's Name*
DOB*

MonthDayYear
Date
Age*
Grade*
Child's Name
DOB

MonthDayYear
Date
Age
Grade
Child's Name
Date

MonthDayYear
Date
Age
Grade
Child's Name
Date

MonthDayYear
Date
Age
Grade
Child's Name
Date

MonthDayYear
Date
Age
Grade
FATHER'S NAME*
Type N/A if not valid
MOTHER'S NAME*
Type N/A if not valid
HOME ADDRESS*
CITY*
ZIP CODE*
CELL PHONE*
HOME PHONE
DOCTOR*
PHONE*
DENTIST*
PHONE*
INSURANCE COMPANY*
POLICY OR ID#*
OTHER EMERGENCY CONTACT NAME*
RELATIONSHIP*
PHONE*
LIST BELOW ANY ALLERGIES OR MEDICAL CONDITIONS OF EACH CHILD IF ANY*
Type N/A if not valid
Office Use Only: Book - Date & Amount Paid Per Clubber: Dues - Date & Amount Paid Per Clubber: Uniform - Date & Amount Paid Per Clubber:
Book Date & Amount Paid Per Clubber

MonthDayYear
Date
Dues Date & Amount Paid Per Clubber

MonthDayYear
Date
Uniform Date & Amount Paid Per Clubber

MonthDayYear
Date
AUTHORIZED PERSONS

It is certainly unfortunate that we live in a society where we MUST be sure the safety of our children is being cared for. We, at First Baptist Church, want you to know that this is very important to us. Therefore, we MUST ask you as parent or guardian to fill out this form. NO other person shall be allowed to pick up your child(ren) from our facility unless they are on this list. This does include all minors whether they are siblings or not. If you feel the child may leave our facility by him/herself without someone picking them up, please list his/her name at the bottom as well. Thank you.
I, blanks*, as the parent or guardian give the following people authority to pick up my children blank .
I understand that as soon as they are picked up from their AWANA rooms they become the sole responsibility of the person who picked them up. First Baptist Church or its staff no longer is responsible for the care of these children. I further understand that identification can be asked for from anyone picking up a child.

Your child will not be allowed to leave with any other persons without written authorization from the parent or guardian.

(I) (We), the undersigned, parent(s) agency, representative or legal guardian, of the above-named child/children, a minor, do hereby authorize the Ministry Leaders of First Baptist Church of San Bernardino, CA as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by and is to be rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the Medicine Practice Act whether such diagnosis or treatment is rendered at the office of said physician or at a hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable.

This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. This authorization shall remain effective from August 14, 2024, thru April 30, 2025, unless sooner revoked in writing delivered to said agent(s).
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: