First Baptist Lynn Haven Church

 2016-2017 AWANA Clubs Permission Slip 

To whom it may concern:


     I give my permission for my child, _________________________, to attend all AWANA activities during the club year.  It is understood that the parents will not in any way hold First Baptist Lynn Haven Church responsible or liable for any accident caused by your child’s disobedience.  I also give permission for emergency treatment by a qualified physician, in case of an accident.  I have included my health insurance number.  As a parent or guardian, I do herewith authorize the treatment by a qualified medical doctor of the following minor in the event of a medical emergency which, in the opinion or the attending physician, may endanger his or her life, causing disfigurement, physical impairment, or undo discomfort if delayed.  This authority is only granted after reasonable effort has been make to reach me.   


Child’s  Name: ________________________________ 


Please print your child’s name as you would like it to appear on any AWANA awards this year): 

(First)|_|_|_|_|_|_|_|_|_|_|_|_|   (Last)|_|_|_|_|_|_|_|_|_|_|_|_|_|_|


Grade entering Fall of 2016: _____                    Birth Date:    ____/____/_______      Circle:  Boy  / Girl


Parents’ / Guardians’ name(s): _____________________             _____________________


Address:______________________________ City:______________ State:___ Zip Code: _______


Home Phone #: ________________________           Cell Phone #: __________________________


E-Mail: |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| @ |_|_|_|_|_|_|_|_|_|_|_|_|  


In case of an emergency, please contact (a responsible adult relative / friend, other than spouse) -  


                       Name: __________________________                        Phone #: ____________________              


Specific food or medical allergies, chronic illness, or other conditions:




Insurance Company: _________________________                                         Policy #: ______________________


Please initial when applicable:

____ My child’s picture, without his/her name, can be put on the AWANA website.

____ Do not put my child’s picture on the AWANA website.

____ I have access to the internet and can view the AWANA newsletter.

____ I do not have internet access and would like a paper copy of the AWANA newsletter.



Signature of Parent/Guardian: _______________________ Date:___________________