*all fields required

Child's Name*

Gender*
MaleFemale

Birthdate*

School Grade as of Sept. 1st, 2022*
---2 years old3 years old4 years old5K1st grade2nd grade3rd grade4th grade5th grade

___________________________________________________________________

PARENTS/GUARDIANS

Name*

Cell Phone*

Email Address*

Name

Cell Phone

Email Address

Address*

City*

State*

Zip Code*

Home Phone*

___________________________________________________________________

Medical concerns, special needs or food allergies*
If none, enter NONE or N/A.

___________________________________________________________________
EMERGENCY CONTACT (only used if parents cannot be reached)
Name*

Phone*

___________________________________________________________________

What church do you attend?*

Where will you (parent/legal guardian) be during Awana?*

Child's Shirt Size*
---2T3T4T5T6TYouth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult Large


Medical/Photo Release

As a parent and/or legal guardian, I do herewith authorize treatment under the direction of any licensed physician of the minor(s) registered above in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life or cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.

The undersigned assumes the responsibility for any cost connected with such treatment, and I understand that the activities at this event can pose risks to personal health and safety. I hereby agree to release Southside Baptist Church and its staff and volunteers from liability in the event of injury.
The undersigned also gives permission for Southside Baptist Church to use any photographic or video likeness of their child for ministry related media productions or brochures publicizing SBC’s Awana Clubs.

A copy of this authorization can be used as the original.

Medical Insurance Provider Name*

Medical Insurance ID*

By checking this box, you verify that this form is completed and submitted of your free will with the sole purpose of authorizing medical treatment under emergency circumstances in your absence.

Type the code you see in the box below.

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