AWANA Club Registration

AWANA Medical Release and Pick Up Authorization

A Medical Release form is required at the beginning of each new AWANA year. Even if your child has been in the program for several years, we ask that you turn in a new form with updated information. Please fill the form out completely so we have the information necessary in case of an accident or emergency.

Please note: Clubbers will be given two weeks to turn in a completed Medical Release form.

After that time, they will not be permitted to participate in games until a completed form has been received.

All children are to be picked up inside the FBC Family Life Center from their AWANA leader. Children will not be permitted to leave the building without appropriate supervision.

Name of Person Submitting Form (Required) *
Child's Full Name *
Child's Age
Grade in School
Student or Child's Birthdate (Required) *
Child's or Student's Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone Number *
Cell Phone

Emergency Contact Information (Required)

Emergency Contact (Required) *Please list name and phone number of who we should contact in case of emergency.

Allergies and Medical Information (Required)

Allergies and Medical Information (Required) If no information or allergies, please write "None" *
Child's Physician (Required) *
Hospital to Use in Case of Emergency (Required) *

Pick-up Privileges (Required)

Who may pick up the student at the end of each Cross Kids session? (Required) *The student will not be released to anyone not included

Consent for Photography (Required)

I give the First Baptist Church of Rogersville Missouri permission to use photographs of me or the child registered here, in its website or social media sites ( such as; Facebook and Instagram) or in its video used in its service. (Required) *
I give my permission to use photographs as indicated above.YesNo

Other Information

Does the student currently attend church regularly? If so, where? (Required)
How did you hear about FBC's AWANA Club Ministry? (website, friend, social media, church sign, church flyer)
By submitting this form, I agree that this release is completed and signed of my own free will with the purpose of authorizing medical treatment under emergency circumstances in my absence.

Verification

Please enter any two digits *Example: 12
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AWANA Club Registration

AWANA Medical Release and Pick Up Authorization