Awana Registration 2019-2020
Dudley Baptist Church
Parental Consent and Release from Liability
Child's Name:
Your answer
Gender
Birthdate:
MM
/
DD
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YYYY
Age:
Your answer
Mailing Address:
Your answer
Parent/Guardian Name:
Your answer
Work Phone:
Your answer
Cell Phone:
Your answer
School:
Your answer
Current Grade:
Your answer
Email Address:
Your answer
The above named minor has my permission to participate in all activities of Dudley Baptist Church, including those summer activities that may place-off campus. I understand that all activities will have adult supervision. I further agree to direct my son/daughter to conform to the fullest with the directions and instructions of the sponsors in charge. I relieve Dudley Baptist Church, its ministers, staff, and counselors from any liability with regard to my child.
Authorization for Medical Care:
I hereby give my permission to the licensed physician, nurse, or medical care provider designated by the group leader to secure medical aid as required for illness or injury under a physician’s orders, including transportation to and from the necessary facilities. I understand that I will be billed for any professional services rendered. I desire for my child to participate in the Awana activities of Dudley Baptist Church for this club year. In consideration of DudleyBaptist Church
providing these activities, I do hereby release Dudley Baptist Church, its officers, employees, agents, and members from all claims and causes of action by reason of an injury that may be sustained as a result of these church activities.
Health Insurance Co. Name:
Your answer
Policy's Holder's Name:
Your answer
Policy Number:
Your answer
Emergency Contact & Number:
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Does your child attend Church? If so where?
Your answer
May we have your permission to photograph your child?
If yes, is it ok to post on social media?
Child's Medical Info:
1. Has he/she had any surgery or serious illness within the last 3 years or any Special Needs?
2. Is he/she required to take medication?
3. Does he/she have any allergies to food or medication?
Parent/Guardian Signature and Date
Your answer
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