Cornerstone Baptist Church

Cornerstone Baptist Church

5736 Inman Rd, Greensboro, NC 27410

336-665-1944

AWANA REGISTRATION and WAIVER FORM 2017-2018 CLUB YEAR

This form must be completed prior to participation in AWANA

Child/Student Info / Date:
Child/Student’s Name: / Sex: Male Female
Address:
City: / State: / Zip:
Birthdate: / Age: / Current Grade:
As of Sept 1st / As of Sept 1st
Allergies:
Space on back for additional children
Parent Info / Parent/Guardian’s Names:
Email(s):
Home Phone:
Cell Phone(s):
How would you like to be contacted if needed? / Call Cell Text Cell Other
Church You Attend:
Safety & Security Info / Emergency Contact Name: / Relationship:
Other than Parent/Guardian / (To Child/Student)
Emergency Contact Phone:
Any special concerns or instructions:
Besides parents/siblings, the following have permission to pick up my child/student:
To whom it may concern: I give permission for my child to participate in all aspects of the Awana Program at Cornerstone Baptist Church. I understand and give permission for my child to participate in Awana program/ games, photographs & give emergency medical release. I also give my permission for my child to be included in physical games that are structured and supervised, but that physical injury is possible with unforeseen circumstances. I (we) also understand that, in the event medical treatment is required, every effort will be made to contact me, however, if I cannot be reached, I give permission to the staff or leader to secure the services of a licensed physician to provide the care necessary, for my child's wellbeing. I (we) also understand that I am responsible for the cost of professional medical emergency care. I do hereby grant permission to record/photograph and display any media, video, and/or film products into any work product used by Cornerstone Baptist Church and to use or authorize the use of such media or any portion thereof in any manner of media or any means, methods or technologies now known or hereafter to be known.
This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence for the Awana Club year, August 31, 2017 thru September 1, 2018.
Parent/Guardian’s Signature:
Child/Student Info / Date:
Child/Student’s Name: / Sex: Male Female
Address:
City: / State: / Zip:
Birthdate: / Age: / Current Grade:
As of Sept 1st / As of Sept 1st
Allergies:
Child/Student Info / Date:
Child/Student’s Name: / Sex: Male Female
Address:
City: / State: / Zip:
Birthdate: / Age: / Current Grade:
As of Sept 1st / As of Sept 1st
Allergies:
Child/Student Info / Date:
Child/Student’s Name: / Sex: Male Female
Address:
City: / State: / Zip:
Birthdate: / Age: / Current Grade:
As of Sept 1st / As of Sept 1st
Allergies: