AWANA Clubs (K-5)

Full Name of Parent / Guardian

Parent Email

This address will receive a confirmation email

Parent Phone

Mailing Address

Emergency Contact Name & Relationship

Emergency Contact Phone Number

Physician's Name

Physician's Phone Number

Consent to photography - NO NAMES will be associated with any photos/videos.

I allow my child to be photographed in Awana for posting within the church website and social media. I do NOT allow my child to be photographed in Awana for any reason.

Child #1 Full Name

Child #1 Birthdate

Child #1

Male Female

Child #1 Grade 2023-24

Child #1 Allergies & Medical Conditions

Child #1 Date of last Tetanus shot

Child #2 Full Name

Child #2 Birthdate

Child #2 Male Female

Child #2 Grade 2023-24

Child #2 Allergies & Medical Conditions

Child #2 Date of last Tetanus shot

Child #3 Full Name

Child #3 Birthdate

Child #3 Male Female

Child #3 Grade 2023-24

Child #3 Allergies & Medical Conditions

Child #3 Date of last Tetanus shot

I hereby authorize the leaders of the Awana Clubs at Grace Baptist Church of Gilbertsville, PA, to act on my behalf when I cannot be contacted, IN CASE OF AN EMERGENCY, resulting in the need for medical attention for my child(ren) listed above. I agree to hold harmless the Awana leadership and GBC Gilbertsville from any accidents as a result of my child(ren)'s participation in its activities. As parent, I hereby consent to any x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by any physician or surgeon licensed under laws of the County/State in which the medical care is being sought, or to consent to treatment to be rendered to the minor by any dentist licensed under the laws of the County/State in which emergency dental care is being sought.

I agree

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AWANA Clubs (K-5)

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