Child's Name (required)

Gender (required)
MaleFemale

Birthdate (required)

School Grade (required)
---2 years old (by Sept. 1)3 years old (by Sept. 1)4 years old5K1st grade2nd grade3rd grade4th grade5th grade

Mother's Name

Mother's Cell Phone

Father's Name

Father's Cell Phone

Address

City

State

Zip Code

Home Phone

Email Address

Medical concerns, special needs or food allergies

Emergency Contact (only used if parents cannot be reached)

Name

Phone

What church do you attend?

Where will you (the parent) be during Awana?

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


Medical/Photo Release

As a parent and/or 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 resonable 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 photgraphic 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.