AWANA 2017-2018
South Fork Baptist Church (Todd, NC)
Child's Name *
Your answer
Gender *
Parent/Guardian Name *
Your answer
Address *
Your answer
City/State/Zip *
Your answer
Home Phone
Your answer
Cell Phone
Your answer
E-mail
Your answer
Birthday *
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Last Grade Completed *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone *
Your answer
Relation to Clubber *
Your answer
People Authorized to Pickup Your Child *
Your answer
Allergies, Medical, & Special Needs
Your answer
Are you a member of South Fork? *
Guest of
Your answer
Do you attend Church *
If so, where?
Your answer
May we have permission to photograph your child? *
If you have never filled out the medical release form or if your information is not up to date please complete.
May we have permission to use your child's photograph in church publications? *
MEDICAL RELEASE (Effective for the Awana Year 2017-2018
If you have never filled out the medical release form or if your information is not up to date please complete the remainder of the Registration.
As a parent and/or guardian, I do herewith authorize the treatment by qualified and licensed medical doctor of the following person 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 reach me.
I also take full financial responsibility for any and all medical services rendered for the above named participant. I am also willing for my insurance company to be billed for any and all medical fees and services should they be needed and to release South Fork Baptist Church, Awana Clubs International, its employees, and its charters from all liability.
Family Doctor
Your answer
Phone Number
Your answer
Insurance Company
Your answer
Policy Number
Your answer
Specific medical allergies, chronic illnesses or other conditions
Your answer
Date of last tetanus shot *
MM
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DD
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