Your Name (required)

Your Email (required)



Church you regularly attend

Child's Name





Home Phone

Parent's Cell Phone


Date of Birth



Allegries and/or Health Conditions

Parent(s) Name or Guardian


1st Emergency Contact

1st Emergency Contact Phone

2nd Emergency Contact

2nd Emergency Contact Phone

Insurance Carrier

Release of Liability, Photo Release, and Consent to Medical Treatment

(Leaving box checked indicates your permission)

Release of Liability

I, myself, my minor child and for the child's parent and/or guardian, hereby release, waive, discharge and covenant not to sue First Baptist Church of Basehor, and its officers, directors, employees, agents, heirs and assigns of and from any loss, damage of injury to my child's person or property in any way resulting from or connected with my child's attendance at AWANA, including without limitation, the failure of anyone to enforce rules and regulations, failure to make inspections, or the negligence of other persons.

Consent to Medical Treatment.

In the event my child becomes ill or injured, I give my permission for a representative of First Baptist Church of Basehor to take whatever steps are reasonably necessary to render emergency first aid to my child. I also consent to such emergency medical or surgical diagnosis and treatment, hospital care and administration of drugs or medicine under the care of a licensed physician and/or surgeon.

Photo Release.

I give my permission for my child's photo, which may be taken during the week, to appear on our board in the foyer, on the screen during Sunday services, posted on the First Baptist Church of Basehor website and/or Facebook page.

AWANA Contact Permission Authorization.

Occasionally your child's handbook leader would like to contact you and your child to see how they are enjoying club and if they need help completing their handbooks. Your child's handbook leader would also like to send written correspondence such as "Get Well" cards and a "Birthday card". By agreeing you are giving your child's leader written permission as the legal parent/guardian to contact you and your child, by written communication and by telephone to discuss club activities.