Esign test

Parent's Name *

First Name Last Name

Phone Number *

- Area Code Phone Number

Address *

Street Address
PO Box
City	State / Province
Postal / Zip Code	Country

Medical Insurance Company and Policy Number *

Emergency Contact and Phone *

Child's Name *

First Name Last Name

Age *

Date of Birth *

Date

Grade *

Current Tetanus *

Yes No

Any Allergies *

Yes No

If "Yes," please describe

Another Child?

Yes No

2nd Child's Name *

First Name Last Name

2nd Child's Age *

2nd Child's Date of Birth *

Date

2nd Child's Grade *

3rd Child?

Yes No

3rd Child's Name *

First Name Last Name

3rd Child's Age *

3rd Child's Date of Birth *

Date

3rd Child's Grade *

4th Child?

Yes No

4th Child's Name *

First Name Last Name

4th Child's Age *

4th Child's Date of Birth *

Date

4th Child's Grade *

Family Doctor and Phone

Brought By

Church Attending

All people allowed to pick up my child(ren) from AWANA *

As a parent or guardian, I do herewith authorize treatment under the direction of any licensed physician of these minors in the event of a medical emergency which in the opinion of the attending physician may endanger his or her life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me by phone at the number listed. The undersigned assumes the responsibility of any costs connected with such treatment and hereby releases the church where the child attends AWANA Clubs from any liability. This release form is completed and signed on my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence. In consideration for being allowed to enter the play area at Grace Church, the undersigned, on his or her behalf, and on behalf of the participant(s) identified herein, acknowledges, appreciates and agrees to the following conditions:

I as parent, or legal guardian of the participant(s) listed below am aware that participating in Grace Church activities and/or use of the play areas and inflatable equipment creates a risk of injury, and I freely assume all such risks both known and unknown even if arising from the negligence of others. I AGREE TO RELEASE, DEFEND, INDEMNIFY, NOT SUE AND HOLD HARMLESS GRACE CHURCH and their employees and volunteers from any claims, damages, (including medical fees and/or attorney fees), injuries (including disabilities, paralysis and death) and expenses arising out of or resulting from my voluntary attendance/participation at Grace Church or the voluntary attendance/participation of those for whom I have signed for below. I as parent/guardian willingly agree to comply with the stated, customary, posted terms, rules, verbal instructions and conditions for attendance/participation. I warrant and certify that all participants (minor/children) are physically fit and able to participate in all activities at Grace Church. If I observe any hazard during our participation, I will bring it to the attention of the nearest Grace Church volunteer. By signing this document, the undersigned gives permission for my child’s likeness in the form of still pictures and/or video and audio to be used by any church sponsored promotional material. I as parent/guardian have carefully read the above participation agreement, assumption of risk acknowledgement and release of liability. I hereby agree to be bound by it for myself and all minor participants listed below, and fully understand the contents. I have the permission from the minor’s family or other responsible party to cover the minor under this agreement.

I am the parent, or legal guardian of the participant(s) named below, or I have obtained permission from the parent/legal guardian of the participant(s) (children/minor) named above to execute this agreement on their behalf.

By signing, I acknowledge that I have read and agree to the waiver as stated above *

Clear

Parent's or Guardian's Name *

First Name Last Name

AWANA Registration