AWANA   2023-2024
South Fork Baptist Church (Todd, NC)
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Child's Name *
Gender *
Parent/Guardian Name *
Address *
City/State/Zip *
Home Phone
Cell Phone
E-mail
Birthday *
MM
/
DD
/
YYYY
Last Grade Completed *
Emergency Contact Name *
Emergency Contact Phone *
Relation to Clubber *
People Authorized to Pickup Your Child *
Allergies, Medical, & Special Needs
Are you a member of South Fork? *
Guest of
Do you attend Church *
If so, where?
May we have permission to photograph your child? *
May we have permission to use your child's photograph in church publications?
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MEDICAL RELEASE  (Effective for the Awana Year 2023-2024)
As a parent and/or guardian, I do herewith authorize the treatment by qualified and licensed medical doctor of the following person in the event of a medical emergency which, in the opinion of the attending physician, may endanger his\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. *
I  also take full financial responsibility for any and all medical services rendered for the above named participant.  I am also willing  for my insurance company to be billed for any and all medical fees and services should they be needed and to release South Fork Baptist Church, Awana Clubs International, its employees, and its charters from all liability. *
Family Doctor
Phone Number
Insurance Company
Policy Number
Specific medical allergies, chronic illnesses or other conditions
Is Tetanus Shot Current? *
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