AWANA 25-26

FULL NAME OF PARENT/GUARDIAN

PARENT EMAIL

This address will receive a confirmation email

PARENT PHONE

MAILING ADDRESS

Emergency Contact

Person to contact in case of an EMERGENCY if parent(s) cannot be reached:

Relationship

Phone

Child #1

Name

Birth Date

Gender

Grade 2025-26

Date of last Tetanus shot

Special medical conditions of minor such as Diabetes, Allergic Reactions, any medications currently using:

I hereby authorize the leaders of the AWANA Clubs at Grace Baptist Church of Gilbertsville, Pennsylvania, to act on my behalf when I cannot be contacted, IN CASE OF AN EMERGENCY resulting in the need of medical attention for my son/daughter named above (other side). I also agree to hold harmless the AWANA leadership and Grace Baptist Church of Gilbertsville from any accidents as a result of my child's participation in its activities. As parent, I hereby consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any physician and surgeon licensed under laws of the State or County in which the medical care is being sought and on the medical staff of any hospital; or to consent to treatment to be rendered to the minor by any dentist licensed under the laws of the State or County in which the dental care is being sought. These authorizations shall remain effective until May 6, 2026 unless sooner revoked in writing.

yes no

I hereby authorize the leaders of the AWANA Clubs at Grace Baptist Church of Gilbertsville, Pennsylvania, to photograph my child(ren) during club events for posting on their website and social media. I understand that NO NAMES will be used with the photos posted.

Yes, I consent. No, I do not.

AWANA 25-26

Description

Please Fix the Following