Registration/Medical Release Form

Male Clubbers Name Grade Birth Date Clubber Who Invited You (If Applicable) Female

Parents or Guardians Address City Home Phone # E-mail Church You Attend Health Insurance Company Insurance ID # Physicians Name Group # Phone # School You Attend State Zip Code Cell Phone #

List any health history we need to be aware of, activity restrictions and/or medication that your child is on:

IMPORTANT: I understand that every effort will be made to protect and safeguard all clubbers. I agree not to hold Parkwood Baptist Church liable for any illness or mishap from any cause whatsoever. In the case of emergency, if I cannot be contacted, I hereby give permission to the Parkwood Baptist Church to secure treatment as necessary for my child, as named above. Please complete the above information and return it with your child to the next AWANA Club Night or e-mail it to: parkwoodbaptistchurch@mail.com. Clubbers will receive $10 AWANA Dollars when this form has been returned. By signing below, you are stating that the above information is correct as listed and that you have received and reviewed the Parent Handbook. Signature of Parent/Guardian Date