Preston Oaks Baptist Church

AWANA

Awana Page 1

page 1 of 1

Name of Child


First Name	Last Name

Age of Child & Last School Grade Completed

Gender of Child

Select one

Female
Male

Address


Address

Address Line 2

City	State	Zip Code

Name of Parent or Guardian


First Name	Last Name

Phone Primary Contact Information for Parent/Guardian

Phone Number

Secondary Contact Information for Parent/Guardian

Phone Number

Email Address

Allergies: Please describe any food allergies or environmental allergies and describe possible reactions that may occur:.

Please list those who are AUTHORIZED to pick up your child from Awana.

Emergency Contact Name (other than parent)


First Name	Last Name

Emergency Contact (other than parent)

Phone Number

I, the undersigned, request that my child (ren) be permitted to participate in the Preston Oaks Baptist Church Awana Ministry. I agree to hold harmless Preston Oaks Baptist Church or any of their agents in the event of accident, illness, injury, or death, which may occur during any and all Awana Sponsored activities. I hereby consent to my child’s participation in interviews, the use of quotes and the taking of photographs, movies or video tapes while participating in a Preston Oaks Baptist Church activity or function. I also grant permission to Preston Oaks Baptist Church to use my child’s name and/or photographs for use in brochures, newsletters, and webpage as well as other forms of media not mentioned. I also hereby release Preston Oaks Baptist Church from all claims, demands, and liabilities whatsoever in connection with the above.

Agreement and endorsement of above paragraph

Select all that apply

YES
NO

* required