AWANA Clubs Registration
2011-2012

Child's Name
Date of Birth
Age
Grade
Parent/Guardian Name(s)
Mailing Address
Physical Address
(if different)
City/State/Zip Code
Phone 1
Phone 2
Email Address
Emergency Contact (other than parent)
Emergency Contact Phone Number(s)
Food/Drug Allergies
Medications taken on a regular basis
Medical conditions of which we should be aware
Today's Date
I have read and accept the Permission & Release Statement

Permission & Release Statement

I hereby give permission for my child to participate in activities sponsored by the AWANA Club of First Baptist Church Grapeland for the club year of 2011-2012. I further give my permission for First Baptist Church Grapeland or its representatives/sponsors of the activity to secure needed medical treatment in the event that I cannot be reached for such permission. I release First Baptist Church Grapeland and its representatives/sponsors from liability for accident or injuries. I hereby accept all the risks of injury associated with the above mentioned activity in which my child is participating at First Baptist Church.

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