(540) 382-0719

AWANA Resurrection Event Registration

Enter your Child's Information Below:

Child's Name*:

Child's DOB*:

Child's Gender:

Grade (Completed)*:

Parents/Guardians*:

Email Address*:

Street Address*:

Home Phone*:

Additional Phone Numbers:

Emergency Contact*:

Emergency Contact Address:

Emergency Contact Phone*:

Person's authorized to pick up my child:

• GSBC's Resurrection Event is called "Journey with Jesus"

• It will be held on Saturday March 27th, 2010

• 10:00 a.m. - 2:00p.m.

• Join us for Food, Crafts, Music and an Egg Hunt!

• For Ages 3yrs - 6th grade

Emergency Medical Authorization:

I/we the parent(s)/guardian of this child authorize Good Shepherd Baptist Church to obtain immediate medical care and consents to the hospitalization of, the performance of necessary diagnostic test upon, the use of surgery on, and/or the administration of drugs to my/our child or ward if an emergency occurs when I/we cannot be located immediately. I/we also understand that this agreement covers only those situations that are true emergencies, and only when I/we expect to be contacted immediately. I/we will be responsible for payment of medical care expenses.

Do you agree with the disclaimer:

My child is currently registered for the 2009/10 AWANA program, please use the medical history information on File:

If you answered "No" to the question above, please complete all of the Medical history information below.

Insurance Company Name:

Insurance Policy Number:

Child's Physician:

Physician's Phone:

Medical History:(Age)

Asthma:

Chicken Pox:

Heart Disorder:

Measles:

Rubella:

Pneumonia:

Whooping Cough:

Diptheria:

Mumps :

Food Allergies:

Allergies:

Seizures:

Actions to take in case of an emergency (in regard to any of the information indicated above):

Has your child attended AWANA at a different Church in the past:

Is your family currently attending a Church:

Comments/Questions