Awana Registration Form

Home Phone Number

Area CodePhone Number
Emergency Contact*

First NameLast Name
Phone Number for Emergency Contact*

Area CodePhone Number
Church Currently Attending
Medical Information:
Please indicate which child has allergies or other medical conditions and what those are.
Family Physician
Physician's Phone Number

Area CodePhone Number
As a parent and/or legal guardian, I do herewith authorize treatment under the direction of any licensed physician of the above-named minors in the event of a medical emergency, which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to contact the parent/guardian by telephone at the numbers given above.

As a parent/guardian, I assume full responsibility for any costs associated with such treatment and hereby release the New Paris Church of the Brethren, AWANA Club, and all club leaders from liability.

This form is completed and submitted of my own free will with the sole purpose of authorizing emergency medical treatment of my son/daughter in my absence.

My signature at the end of this form indicates that I have read and agree to the terms listed above.

Authorized Individuals:

The following people (other than parents or guardian) have permission to drop off and pick up my child(ren):
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to the child/children
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to the child/children

Will you and your children be joining us for supper on October1st? If so, how many of you will be there?
Yes No If yes, how many?
Release:
Permission of Participation:

I understand that my child/children may participate in physical 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 to the New Paris Church of the Brethren, its staff, and any persons involved in the Awana Club ministry.

Photo Release:

I give permission for the New Paris Church of the Brethren to use photos/videos of my child/children in promotions, including on the church's website.

Contact Release:

I grant permission for the Awana staff to contact my child/children by mail, email, or phone.

Facebook Release:

I give permission for my child(ren)’s name and picture to be posted on the Awana at NPCOB Facebook page.

Information Release:

By completing this form, you agree to allow the New Paris Church of the Brethren leaders and staff to use the information you have provided to assist us in caring for your child during Awana.
My signature below designates that I have read and agree to the terms listed above.
Signature*

Clear
Should be Empty:

Parent Information: