AWANA CLUBBER REGISTRATION/MEDICAL RELEASE FORM 2022 - 2023
Spinning Road Baptist Church- 538 Spinning Road, Riverside, OH 45431 (937) 252-5311
(For Club meetings and all supervised Awana outings)

To enroll your child in the Awana Club at Spinning Road Baptist Church, please complete this form.  Awana registration personnel will print out the form and have you sign it later.
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CHILD'S INFORMATION:
Child's First Name *
Child's Last Name *
Nickname
(if any)
Age *
Gender *
Required
Birth Date *
MM
/
DD
/
YYYY
Grade *
(Grade as of fall 2022)
Please identify any food allergies *
Put "none" or "N/A" if there are no known food allergies
Please identify any allergies, medical conditions, and/or Special Information (Medications, activity restrictions) that we should be aware of *
Put "none" or "N/A" if there are none
PARENTS/LEGAL GUARDIAN INFORMATION:
Parent(s) / Guardian(s) Name(s) *
Best Phone Number to Reach Parent/Guardian (include area code) *
Optional secondary phone number (include area code)
Address *
City *
State *
Zip *
Home Email Address *
(** Our primary way of communication - For Club announcements and updates)
Are you currently affiliated with a church? *
(if yes, where?)
EMERGENCY CONTACTS:
Emergency Contact during Awana *
(Other than Parent(s) or Guardian on this form)
Emergency Contact Relationship to Child *
Best Phone # to Reach Emergency Contact (include area code) *
Optional secondary emergency contact phone number (include area code)
INSURANCE INFORMATION:
In the event your child needs medical attention, please provide your insurance information below.
Doctor's Name
Doctor's Phone Number
Dentist's Name
Dentist's Phone Number
Health Insurance company - in the event your child needs medical attention
Health Insurance policy #
Medical RELEASE Authorization
The above-named child has my permission to participate in all Awana activities on and off campus (providing I have been notified in advance). In case of a medical emergency, I the parent/guardian of the above-named child, hereby authorize the physician/hospital selected by SRBC staff/volunteers to consent for any x-ray, medical, dental, examination, anesthetic, release of insurance records; medical or surgical treatment, and hospital care which is advised and supervised by a licensed physician, surgeon, or dentist. which in the doctor’s opinion, may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if delayed for the above-named child. I authorize an adult leader of SRBC’s Awana Staff, authority to act as agent for me, on behalf of my above-named child to; provide or arrange necessary related transportation, including paramedics, and ambulance transport. This authority is granted only after a reasonable effort has been made to contact me or my emergency contact. I also accept responsibility for and agree to fully pay all expenses of medical or dental care incurred through such treatment. I hereby release Spinning Road Baptist Church, Pastor, volunteers, agents, and vehicle driver of any vehicle driven (if transportation is part of an event) from liability. 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. I understand that if my child does not behave in an appropriate manner, I may be contacted to come pick up my child and remove them from the church property/event.
Photo/Video Release
Photos/Videos taken during the Club year are utilized for church publications and year-end slide show to promote the activities of our Awana club. If you would prefer not to have individual pictures of your child included, please designate below. We cannot guarantee that your child will not be included in group photos/video of Awana events.
Individual pictures of my Child at Awana events *
(Check one)
Required
Person (s) other than Parents authorized to pick child up
(please note: your child will not be let go to anyone that is not listed)
Thank you for beginning the registration process by filling out this electronic form.  Awana registration personnel will print out the form and have you sign it at the check-in table the first night you attend club.  Press the submit button below to complete the sign-up process.
Parent/Guardian Signature
(Awana registration personnel will print out the form and have you sign it later.)
Date of signature
(when you sign the form, please put the date here)
Submit
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