Birthdate of Child #1 *

MM

DD

YYYY

Birthdate of Child #2

MM

DD

YYYY

Birthdate of Child #3

MM

DD

YYYY

Birthdate of Child #4

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Cell Phone

(###)

###

####

Father's Cell Phone

(###)

###

####

Medical Release *

I give permission for my child/children to participate in the First Baptist Church AWANA Club. Should any emergency medical treatment be necessary, I do hereby authorize an adult AWANA Leader to act on my behalf and approve the appropriate treatment. I further authorize any physician, hospital or medical attendant to receive full and complete medical reports or information necessary with respect to the treatment of my child.

I authorize

I do not authorize

Photo Release *

I, grant First Baptist Church AWANA Club of Spencer, Iowa, my permission to use photographs taken during AWANA Club nights for any legal use, including but not limited to: publicity, copyright purposes, illustration, advertising, and web content. Furthermore, I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.

I authorize

I do not authorize