First Baptist Church Matthews, NC

First Baptist Church of Matthews
AWANA Club Registration
September 2009-May 2010
Sunday Nights 5:15-7:00pm

Please complete the following:

Parents' Name(s):

Home Address: 

City:   State:   Zipcode:

Phone(home):    Phone(cell):

Parents email:

Do you have a church home? YESNO
If YES, where?

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Please Note: Cubbies Enrollment (3 &4 yr olds) is available for children whose parents remain on campus for discipleship training or are in service with Awana or Student Ministry.  Cubbies must be 3 years old by August 31, 2009.

Child #1 Name:   Grade (2009-2010): preschool 3yr or 4yrTKK123456  Age:

Birthdate(mm/dd/yyyy):   Gender: MF

Child #2 Name:   Grade (2009-2010): preschool 3yr or 4yrTKK123456  Age:

Birthdate(mm/dd/yyyy):   Gender: MF

Child #3 Name:   Grade (2009-2010): preschool 3yr or 4yrTKK123456  Age:

Birthdate(mm/dd/yyyy):   Gender: MF

Child #4 Name:   Grade (2009-2010): preschool 3yr or 4yrTKK123456  Age:

Birthdate(mm/dd/yyyy):   Gender: MF

Medical/Safety Information
Medical or other information we need to know(include allergies, medications, special needs, activity restrictions):


In the event of an emergency, whom do we call if parents cannot be reached at the phone numbers above?
Name:    Phone:

Physician Name:    Phone:

Authorized Adults:
All children will need to be picked up at their classroom door by an authorized adult unless special instructions are listed.
Please list any adults authorized to pick up your child:

Special pickup instructions:

Insurance Information
Our church's insurance is only secondary insurance.  If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your son or daughter is on a church related activity.
Do you have health insurance? YESNO
If yes, please list the name of the carrier:

Policy Number:

Address:

LIABILITY RELEASE-FOR ALL AWANA PARTICIPANTS

Every activity sponsored by this church is carefully planned and adequately supervised by mature adults.  However, even with the best of planning and precaution, unforseen events can occur.  By signing this form, the parent or gaurdian agrees to assume and accept all risks and hazards inherent in church related social activities.

In the event that I cannot be reached in an emergency during the dates specified on this form, I hereby give my permission to hospitalize, to secure proper treatment and/or order an injection, anesthesia or surgey for my son or daughter as deemed necessary.

I also agree not to hold this church, First Baptist Church of Matthews, or its employees or volunteer assistants or Awana Clubs Internatioanl liable for damages, losses, or injuries to the person or property undersigned.  The parents or guardians understand that they are signing for the minor listed on this forma dn the signature is both a medical and liability release.

Parent or Guardian Signature:

Date:

By submitting this form you agree to the liability and medical release.