IMPACT (Grades 6-12)
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Full Name of Parent / Guardian
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Parent Email
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This address will receive a confirmation email
Parent Phone
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Mailing Address
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Emergency Contact Name
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Emergency Contact Phone Number
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Physician's Name
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Physician's Phone Number
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Consent to photography - NO NAMES will be associated with any photos/videos.
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Please select one option.
I allow my child to be photographed in IMPACT for posting within the church website and social media.
I do NOT allow my child to be photographed in IMPACT for any reason.ion
Child #1 Full Name
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Child #1 Birthdate
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Child #1
*
Please select one option.
Male
Female
Child #1 Grade 2023-24
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Child #1 Allergies & Other Important Information
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Child #1 Date of last Tetanus shot
*
Child #2 Full Name
Child #2 Birthdate
Child #2
Please select one option.
Male
Female
Child #2 Grade 2023-24
Child #2 Allergies & Other Important Information
Child #2 Date of last Tetanus shot
Child #3 Full Name
Child #3 Birthdate
Child #3
Please select one option.
Male
Female
Child #3 Grade 2023-24
Child #3 Allergies & Other Important Information
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.
*
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I agree
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Description
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