Parent or Legal Guardian Name
*
First Name
Last Name
Relationship to child(ren)
Choose one
Parent
Legal Guardian
Other
Primary Phone
*
(###)
###
####
Secondary Phone
(###)
###
####
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Check the box below if emergency contact is same as above. (If so, you may leave these emergency fields blank.)
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Primary Phone
(###)
###
####
Emergency Contact Secondary Phone
(###)
###
####
Your medical insurance carrier name & policy number
Alternate Pickup Name
First Name
Last Name
Alternate Pickup Phone
(###)
###
####
Child #1 Name
*
First Name
Last Name
Child #1 Gender
*
Child #1 Age (at start of current school year, Sept 1)
*
Choose one
5
6
7
8
9
10
11
12
13
14
15
16
Child #1 Grade (at start of current school year)
*
Choose one
Not in school year
K
1
2
3
4
5
6
7
8
9
Child #1 Special Needs
(Food allergies, medications, etc)
Child #2 Name
First Name
Last Name
Child #2 Gender
Child #2 Age (at start of current school year, Sept 1)
Choose one
5
6
7
8
9
10
11
12
13
14
15
16
Child #2 Grade (at start of current school year)
Choose one
Not in school year
K
1
2
3
4
5
6
7
8
9
Child #2 Special Needs
Child #3 Name
First Name
Last Name
Child #3 Gender
Child #3 Age (at start of current school year, Sept 1)
Choose one
5
6
7
8
9
10
11
12
13
14
15
16
Child #3 Grade (at start of current school year)
Choose one
Not in school year
K
1
2
3
4
5
6
7
8
9
Child #3 Special Needs
Child #4 Name
First Name
Last Name
Child #4 Gender
Child #4 Age (at start of current school year, Sept 1)
Choose one
5
6
7
8
9
10
11
12
13
14
15
16
Child #4 Grade (at start of current school year)
Choose one
Not in school year
K
1
2
3
4
5
6
7
8
9
Child #4 Special Needs
Child #5 Name
First Name
Last Name
Child #5 Gender
Child #5 Age (at start of current school year, Sept 1)
Choose one
5
6
7
8
9
10
11
12
13
14
15
16
Child #5 Grade (at start of current school year)
Choose one
Not in school year
K
1
2
3
4
5
6
7
8
9
Child #5 Special Needs
Are you the parent or legal guardian of all minors listed in this registration, and as such do you agree to the Awana liability, medical, and image releases included below?
*
LIABILITY RELEASE
Every activity in the Discovery Baptist Church (DBC) AWANA program is carefully planned and supervised. However, even with the best planning and precaution, unforeseen events and injuries can occur. By registering in the DBC Awana Club I agree to assume and accept all risks and hazards inherent in AWANA-related activities at DBC. I also agree not to hold this church or its employees or volunteer assistants liable for any injuries to the minor(s) listed in my registration, except for cases of gross negligence.
MEDICAL RELEASE
In the event I cannot be reached in an emergency during the club night at DBC, I hereby give my permission to the physician or dentist selected by this AWANA club leadership or church leadership to hospitalize, to secure proper treatment, and/or order an injection, anesthesia, or surgery for my child as deemed necessary.
IMAGE RELEASE
I understand that church events are often photographed/recorded for publication and public relations (i.e. end-of-year videos, website promo’s, flyers, etc), and I hereby grant irrevocable permission to the DBC AWANA Club to indefinitely use photos/videos of my child(ren) for these purposes (including, but not limited to print, screen projection, the internet, etc). I waive my right to inspect and approve such use, but such use must be related solely to this AWANA Club and church and must not identify my child by name. I release the church from any and all claims arising out of said use, including but not limited to claims of libel and invasion of privacy.
