Name of Parent/Guardian *

First Name

Last Name

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Child #1 Birthday *

MM

DD

YYYY

Child #2 Birthday

MM

DD

YYYY

Terms and Condidtions *

1.) I consent to and approve my child/children’s taking part in any and all activities conducted by Leavenworth Baptist Church AWANA Clubs. 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 consent to the treatment of any minor injuries of my child/children, and release, hold harmless and indemnify AWANA and the Church and their officers, directors, agents, employees and volunteers from any and all liability, claims and costs arising from or growing out of such treatment. 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. 2.) I give permission for photo(s) of my child/children to appear among other general club photos in any and all media as long as there is no identifying information published. I hereby waive any causes of action I may have because of the use of my child’s photograph.

I have read and agree to the Terms and Conditions stated above.