Faith Baptist Church
2010-2011 AWANA Clubs Permission Slip

To whom it may concern:

     I give my permission for my child, _________________________, to attend all AWANA activities during the club year. It is understood that the parents will not in any way hold Faith Baptist Church responsible or liable for any accident caused by your child's disobedience. I also give permission for emergency treatment by a qualified physician, in case of an accident. I have included my health insurance number. As a parent or guardian, I do herewith authorize the treatment by a qualified medical doctor of the following minor in the event of a medical emergency which, in the opinion or the attending physician, may endanger his or her life, causing disfigurement, physical impairment, or undo discomfort if delayed. This authority is only granted after reasonable effort has been make to reach me.

Child's Name: __________________________________

Grade entering fall of 2010: _____
Birth Date:    _____/_____/________

Parents' / Guardians' name(s): _____________________       _____________________
*Please indicate if there is a special situation or circumstance that we need to be aware of.

Address (including zip code):____________________________________________________
__________________________________________________________________________

Home Phone #: ___________________     Cell Phone # (optional): ______________________

In case of an emergency, please contact (a responsible adult relative / friend, other than spouse) -

Name: ____________________________________

Phone #: ____________________     Relationship to child: ________________________

Child's Physician: ____________________    Physician's Phone #: ______________________

Specific medical allergies, chronic illness, or other conditions that we need to be informed of:
__________________________________________________________________________
__________________________________________________________________________

Insurance Company: _________________________   Policy #: ______________________

Save time in the registration line by printing out the registration form, filling it out, and bringing it with you your first night of club.

Signature of Parent/Guardian: __________________________   Date: ___________________