Jeffersonton Baptist Church AWANA Clubs

Minor Child Registration, Liability and Release Form

Parental Consent

The undersigned do hereby give permission for my child (child’s name)(“Clubber”), to attend and participate in Awana Clubs at Jeffersonton Baptist Church for the upcoming 2016-2017 club year.

LIABILITY RELEASE: In consideration of Jeffersonton Baptist Church allowing the Clubber to participate in Awana Clubs, I, the undersigned, do hereby release, forever discharge and agree to hold harmless Jeffersonton Bapsist Church, its pastors, directors, employees, volunteers and teachers (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Clubber while involved in Awana Clubs. I, the parent or legal guardian of this Clubber, hereby grant my permission for the Clubber to participate fully in Awana Club activities including trips away from the church premises. Furthermore, I, on behalf of my minor Clubber, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of said Clubber, including expenses incurred attendant thereto.

MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency first aid treatment to be rendered to the minor under the general or special supervision and on the advice of a certified emergency medical provider.  The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical services rendered to the aforementioned child or youth pursuant to this authorization.

TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my child/youth to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by Jeffersonton Baptist Church. My child/youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.


Name of parent/guardian                                 Signature of parent/guardian *                                 Date



Clubber’s Full Name  Birth Date 

Home Address  


Phone Shirt Size

Names of siblings attending clubs;;;

; ; ; ;


Parent/Guardian Name:  Phone:(cell) Text?  Y  N Alternate phone/(home) Email address:


Name: Relation:

Cell Phone         Alternate Phone:

List below ALL individuals (other than parent/guardian) who are approved to pick up your child from clubs*


Name                                                                Relationship


Name                                                                Relationship


Name                                                                Relationship

*Please note: To ensure the safety of all clubbers, children will NOT be allowed to leave clubs with anyone who has not been listed here without prior arrangements or notification being made to Awana Clubs Commander before clubs begin .. no exceptions.  



List all medications the youth will take during Awana activities.  This includes any prescription or non-prescription medications.  Any participant under the age of 18 is required to give ALL MEDICATIONS to the Awana Commander or Adult Club Leader in their original containers with complete dispensing instructions before the start of club nights. Clubbers are not permitted to carry any prescription or non-prescription medication unless notification is given to Awana Commander prior to club nights.

Medication Name                Dose                Treatment for                Dispensing instructions

Example:   Albuterol Inhalder -Metered          asthma                        2 puffs every 4 hours as needed         ___



MEDICAL CONDITIONS: Please answer if applicable or write N/A. Attach additional pages if necessary.

1.        List any medical conditions your child has (asthma, diabetes, epilepsy, etc.):

2.        List any allergies (drug/medicine, food, and/or environmental) and the severity and type of reaction:

Print and mail this form to:


℅ AWANA CLubs Commander, Beverly Smith

18498 Springs Rd

Jeffersonton, VA 22724-1916


E-MAIL:   AWANA CLubs Commander,  <>

*Note, submission via e-mail is acceptable, but will require signature of parent or Guardian listed above on arrival for first day at Club activities.

 of 3