CHILLICOTHE BAPTIST CHURCH
14000 ST RT 104
CHILLICOTHE OHIO 45601
2009-2010 AWANA REGISTRATION
**FORM MUST BE FILLED OUT BEFORE CLUBBER IS INVOLVED IN ANY ACTIVITY**
Church Phone: 773-1525
Child’s First Name: _____________________________________ Child’s Last Name: ____________________________________________
Age: _______________________ Birth Date: _______________________________________ School Grade: ________________
(Awana must be K-6 grades. An older sibling must accompany Kindergartners)
Parent’s Name: ____________________________________________________________________________________________________________
Address: _________________________________________________________________________________________________________________
City: _______________________________________________________________ Zip Code: ________________________
Home Phone: __________________________________ Other Phone: ________________________________________
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Photographs are sometimes taken of children's ministry activities for publicity and promotional purposes, which include, but are not limited to, in-house presentations, church web sites, brochures and newsletters. Children's names or information are never used without specific permission. By signing this area, you are releasing Chillicothe Baptist to use photographs of your child as stated above.
Signature of Parent/Guardian:_________________________________________Date: _______________________________ |
I grant permission for Chillicothe Baptist Church to transport my child/children on buses for the AWANA year. I understand that they are to obey the rules of conduct of the church and the church workers. The rules are established for the safety and comfort of all passengers. They may be denied bus privileges for breaking the rules.
BLANKET AWANA MEDICAL RELEASE FOR THE YEAR 2009-2010
As a parent and/or guardian, I authorize treatment under the direction of any licensed physician of the following minor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me by the phone numbers listed below.
The undersigned assumes the responsibility for cost connected with such treatment and hereby releases the church where the children attend from any liability therefore.
NAME OF MINOR: ______________________________________RELATIONSHIP: _________________________________________________________
PHONE #1: _____________________________________________ PHONE #2: ___________________________________________________________
ADDRESS: ______________________________________________________________________________________________________________________
FAMILY PHYSICIAN: ______________________________________________________PHONE: ______________________________________________
DATE OF LAST TETANUS SHOT: _______________________________________
THIS RELEASE FORM IS COMPLETED AND SIGNED OF MY OWN FREE WILL WITH THE SOLE PURPOSE OF AUTHORIZING MEDICAL TREATMENT UNDER EMERGENCY CIRCUMSTANCES IN MY ABSENCE.