Holly Springs Baptist Church Registration and Release FormEffective dates: August 13, 2017-August 30, 2018Name: First Last Age: Birthdate:01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901daymonthyearYear in School: Gender:MaleFemaleE-mail:Address: Street AddressCityState / Province / RegionPostal / Zip Code Mother's Name: First Last Mother's Phone Home: Area Code - Phone Number Mother's Phone Cell: Area Code - Phone Number Father's Name: First Last Father's Phone Home: Area Code - Phone Number Father's Phone Cell: Area Code - Phone Number Emergency Contact: First Last Emergency Contact Phone Home: Area Code - Phone Number Emergency Contact Phone Cell: Area Code - Phone Number Physician: Physician Office Phone: Area Code - Phone Number Dentist: Dentist Office Phone: Area Code - Phone Number Medical HistoryMedical profile generally, the participant's health is: ExcellentGoodFairPoorIf 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:AsthmaSinusitusBronchitisKidney TroubleHeart TroubleDiabetesDizzinessUpset StomachHay FeverExplain 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:ChickenpoxMeaslesMumpsWhooping CoughOtherDate of Tetanus Imminization:01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 201720162015201420132012201120102009200820072006200520042003200220012000daymonthyearInsurance Co.: Policy #: Subscriber Name: Subscriber Number: Employment: Subscriber Occupation: Work Phone: Area Code - Phone Number Terms and Conditions: 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.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.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.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.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 ChurchPlease go over the following expectations with your children.We expect the child/children to: Respect one another, staff, and adult leaders;Respect property;Respect and comply with the event schedules; and Demonstrate the Fruit of the Spirit (Love, Joy, Peace, Patience, Kindness, Goodness, Faithfulness, Gentleness and Self-control), in all situations.Parent/Guardian Signature: First Last Date:01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 201720162015daymonthyearWord Verification:SubmitReset