Holly Springs Baptist Church Registration and Release Form

Effective dates: August 13, 2017-August 30, 2018
Name:
Age:
Birthdate:
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Year in School:
Gender:
E-mail:
Address:
Mother's Name:
Mother's Phone Home:
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Mother's Phone Cell:
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Father's Name:
Father's Phone Home:
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Father's Phone Cell:
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Emergency Contact:
Emergency Contact Phone Home:
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Emergency Contact Phone Cell:
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Physician:
Physician Office Phone:
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Dentist:
Dentist Office Phone:
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Medical History

Medical profile generally, the participant's health is:
If fair or poor, please explain the condition:
List any medical difficulties which are currently being treated:
Check any of the following that cause you problems & explain:
Explain any of the above checked conditions:
List any medicines or substances to which you are allergic:
List any previous operations or serious illnesses:
List any medications you are currently taking:
List any special diet or special needs or food allergies::
Childhood Diseases:
Date of Tetanus Imminization:
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Insurance Co.:
Policy #:
Subscriber Name:
Subscriber Number:
Employment:
Subscriber Occupation:
Work Phone:
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Terms and Conditions:

  1.  I understand that my child/children may participate in physical activities such as those held during Game Time.  As with any physical activity, there is a risk of injury.  I fully accept this risk and hold harmless from any legal liability, HSBC and any persons involved in the AWANA Club ministry.
  2. In the event of an emergency that requires medical treatment for the above named child/children, I understand every effort will be made to contact me or my emergency contact.  However, if I/we cannot be reached, I give my permission to the AWANA volunteers to secure the services of a licensed physician to provide the care necessary for  my child's well-being.  I assume responsibility for all costs connected to any accident or treatment of my child.
  3. I grand permission for a photo of my child to appear in an unpublished club directory to be used by AWANA leaders only.  I also give permission for photo(s) of my child to appear on the church's website as long as there is no identifying information shown.
  4. I grant permission for my child to travel to/from AWANA club events with an adult leader.  Any such event will be clearly communicated with me beforehand.
  5. Each child must be signed in on arrival and out on departure by the parent, not a sibling.  Safety is a priority at Holly Springs Baptist Church

Please go over the following expectations with your children.

We expect the child/children to:

  1.  Respect one another, staff, and adult leaders;
  2. Respect property;
  3. Respect and comply with the event schedules; and 
  4. Demonstrate the Fruit of the Spirit (Love, Joy, Peace, Patience, Kindness, Goodness, Faithfulness, Gentleness and Self-control), in all situations.
Parent/Guardian Signature:
Date:
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Word Verification: