LP Registration Form 2025-2026

LP Registration Form 2025-2026

If you are filling this form out on a phone or tablet, landscape view works best when filling in the Child/Children's Information table.

Child/Children's Information

Medical Release
Are there any allergies, medical needs, or other conditions for your child/children we should be aware of?

YesNo
Please list special needs or allergies for each child below
As a parent and/or guardian, I do herewith authorize treatment under the direction of a licensed physician of the above minor in the event of a medical emergency which in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me by phone at the phone number listed below.

The undersigned assumes the responsibility for any cost connected with such treatment and hereby releases Bethel Baptist Church from any liability therefore.

The release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence
Signature for Medical Treatment Authorization

First NameLast Name
Please indicate your role of the above signed

FatherMotherGuardian
Family Physician
Physician Phone
Health Insurance Name
Health Insurance Number
Insurance Phone Number
Please enter a valid phone number.
Additional Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.

Are there any Family Court Orders in place with your family?

YesNo
Please explain your family court orders
Unauthorized to Pickup
Please indicate if there is anyone whom you do not want you child/children released to
Image Release

I understand that church events are often photographed/recorded for publication and public relations (i.e. end-of-year videos, website promo’s, flyers, etc), and I hereby grant irrevocable permission to the Bethel Baptist Church AWANA Club to indefinitely use photos/videos of my child(ren) for these purposes (including, but not limited to print, screen projection, the internet, etc). I waive my right to inspect and approve such use, but such use must be related solely to this AWANA Club, AWANA activities, and church and must not identify my child by name. I release the church from any and all claims arising out of said use, including but not limited to claims of libel and invasion of privacy.
Name

First NameLast Name
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