2018-2019 AWANA Clubs Permission Slip
Faith Baptist Church | 2111 Kuser Road, Hamilton Square, NJ
By filling out this form, you are granting the following:
I give my permission for my child, to attend all AWANA activities during the club year.
It is understood that the parents will not in any way hold Faith Baptist Church responsible or liable for any accident caused by your child’s disobedience. I also give permission for emergency treatment by a qualified physician, in case of an accident. I have included my health insurance number. As a parent or guardian, I do herewith authorize the treatment by a qualified medical doctor of the following minor in the event of a medical emergency which, in the opinion or the attending physician, may endanger his or her life, causing disfigurement, physical impairment, or undo discomfort if delayed. This authority is only granted after reasonable effort has been make to reach me.
Child's first name *
Your answer
Child's last name *
Your answer
Grade entering in the fall of 2018 *
Child's date of birth *
MM
/
DD
/
YYYY
Gender *
Parents’ / Guardians’ name(s): *
Your answer
Address *
Street Address, City, State, Zip Code
Your answer
Email
Your answer
Cell phone number
Your answer
House phone number
Your answer
Emergency Contact Information *
In case of an emergency, please contact (a responsible adult relative / friend, other than spouse) . Please provide a name AND phone number to contact.
Your answer
Specific food or medical allergies, chronic illness, or other conditions:
Your answer
Insurance Information
Insurance Company and Policy Number
Your answer
Please check all that apply
Digital Signature *
Please sign your name below to grant permission for your child to attend the AWANA Club at Faith Baptist Church.
Your answer
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