First Baptist Church of Citrus Park AWANA 2014 – 2015 Registration

The Entire Registration MUST Be Completed By The Child’s Parent or Legal Guardian

3 Yrs. 4 Yrs.
BOY GIRL
Please list your Child’s Shirt Size: _____ /
K-5 1st Gr. 2nd Gr.
BOY GIRL
Please list your Child’s Shirt Size: _____ /
3rd 4th 5th 6th
BOY GIRL
Please list your Child’s Shirt Size: _____
Child’s First Name: Child’s Last Name:
Date of Birth: Age: Name of School:
Parent’s or Legal Guardian’s Name:
Your location during AWANA:
Home: ([]) Cell: ([]) Email:
Address including City, Stateand Zip Code
What church do you attend?
Are you a member of that church? YES or NO
Would you like to learn more about First Baptist Church of CitrusPark? YES or NO
Name of person bringing child to or picking child up from AWANA if not parent or guardian

Emergency/ Medical Information

Allergies/Special Health Considerations
Secondary Adult Contact, In the event, that the parent/guardian can not be reached:
Name Relation to child
Home: ([])
Cell: ([])
Address including City, Stateand Zip Code
Hospital/Clinic Preference
Physician’s Name
Phone Number
Insurance Company
Policy Number / Hospital/Clinic Preference

Parent/Legal Guardian Consent

_____ I do NOT authorize OR _____ I do authorize
a representative of First Baptist Church of Citrus Park to make such arrangements as s/he considers necessary for my child to receive all medical/dental and surgical treatment, X-ray, laboratory, anesthesia, including necessary transportation and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency. Under such circumstances, I further authorize the physician named above to undertake such care and treatment of my child as s/he considers necessary. In the event said physician is not available, I authorize such care and treatment to be performed by any licensed physician, dentist, or surgeon. The undersigned parent/guardian fully understands s/he is responsible to pay all costs incurred as a result of the foregoing.
_____ I do NOT authorize OR _____ I do authorize
FirstBaptistChurch of CitrusPark to use my child’s likeness, voice, or performance, which may be recorded on various forms of published media. I understand that this may be used by the ministry in publications for the means of education, instruction or information. I also understand that these publications may include, but are not limited to audiovisual productions, brochures, posters, pamphlets, DVD or CD programs, as well as, First Baptist Church of Citrus Park Ministry media web pages.
Parent’s/Legal Guardian’s Signature ______Date ______
Parent’s/Legal Guardian’s PRINTED Name ______

Clubbers and Parent’s/Legal Guardian’s Please Note:

Dues: Fifteen Dollars per year OR Fifty Cents Weekly AWANA Hours: 6:30PM – 8:00 PM
Safety: Please make sure the clubbers wear tennis shoes & socks to AWANA.
Please do NOT send your child to AWANA with heelys or any type of skate shoe. / Club Hours: 6:30PM – 8:00 PM