I give _____ permission to attend

Document Sample
I give _____ permission to attend Powered By Docstoc
					     Please fill out each of the four forms completely. Then fax, mail, or drop them off at VBC at your
     convenience. Please include a check made out to Victory Baptist Church in the amount on page 2
  (according to your payment plan). The orders for supplies will go out Thursday, Sept. 18th (the day after
  Registration Night); if your information is not in by Wednesday, your child may receive their workbook,
                                              uniform, etc. later.
                 If you have any questions, please contact the church office at 703-594-2933.

                                2008-2009 AWANA REGISTRATION FORM
                                      Please fill out ONE PER CHILD!

This student is in:           CUBBIES                       SPARKS                       GO AND DO

Name: ____________________________________________________________________________________

             Street                              City        State       Zip

Home Phone Number: _______________________________________________________________________

Mother’s Name:_______________________________ Does he/she live with mom?  Yes  No  Sometimes

Father’s Name:_________________________________ Does he/she live with dad?  Yes  No  Sometimes

Does your family attend church regularly?  Yes  No

If so, where? _______________________________________________________________________________

Birthday: ___________ - _____________ - _______________

Siblings: # of older brothers ____, # of younger brothers ____, # of older sisters ____, # of younger sisters ____

What school does/will the student attend? ________________________________________________________

Please list all the people who you give permission to pick up your child from AWANA (anyone not on this list
will not be allowed to leave VBC with your child). Please include all names:
                                              REGISTRATION COSTS
                                       Please fill out ONE PER FAMILY.
 The registration cost covers all the activities, games, snacks, etc. on Sunday AWANA meeting time as well as
awards throughout the year. The registration fee does not cover activities or events outside of regular AWANA
    meeting time (i.e. Grand Prix, Camping Trip, etc.). To find your family’s total cost, please fill out the
 “Materials” section and the “Registration” section and add them together. The double box near the bottom of
                          the page is your Family’s Total AWANA Cost for the year.

Last Name: ________________________________________________________________________________

Children’s first names: _______________________________________________________________________


Cubbies Materials      Book         Qty._____ x $8 =   _____ (all Cubbies need to order a book)
                       Uniform      Qty._____ x $8 =   _____ (see sample vest in classroom)
       Please indicate which size uniform:  25”           27”        29”            31”          33”
                       Bag          Qty._____ x $6 =   _____
                       CD           Qty._____ x $10=   _____ (cassettes are available for $5 each)

Sparks Materials      Book         Qty._____ x $7 = _____
      Please indicate which book:  1st book (Skipper)  2nd book (Hiker)  3rd book (climber)
                      Uniform      Qty._____ x $10 = _____ measure all the way around the child
      Please indicate which size uniform:  28”      30”    34”      37”      38”
                       Bag         Qty._____ x $5 = _____
                       CD          Qty._____ x $10= _____        (cassettes are available for $5 each)

Go and Do Materials  Book          Qty._____ x $2 = _____
                      Uniform      Qty._____ x $15 = _____
      Please indicate which size uniform (youth sizes):  small    medium         large       x-large

                                                             Materials total cost $___________

 Number of children            1            $20
                               2            $35
                               3            $45
                                4 or more   $50
                                                     Materials total cost + Registration fee = TOTAL

                                                     _______________ + _____________ =
                Registration fee $_____________

                       I would like to pay:  total cost now OR  half now & half in Feb.
       Please note: if not paying the full amount now, we will mail you a reminder of the other payments
                                             Permission To Use Pictures
In consideration for value received, receipt whereof is acknowledged, I hereby give Victory Baptist Church, all
of her employees, representatives, and delegates the absolute right and permission to publish, copyright and use
pictures of me in which I may be included in whole or in part, composite or retouched in character or form.
I certify that I am the above listed child’s parent or legal guardian and I give my consent without reservation to
the foregoing on his or her behalf.

                          Parental Consent, Liability Release, & Medical Information
The undersigned(s) being the lawful parent(s) and/or guardian(s) of the above child (the "Child"), hereby
consents to the participation by the Child in AWANA conducted by Victory Baptist Church and to the
participation of the Child in all events relating to the activity each Wednesday from September 2008 through
May 2009, 6:30 P.M. until 8:00 P.M.
The undersigned hereby further authorize(s) any of the staff, employees, agents and representatives of
Organizer to provide for, approve and authorize any health care at any hospital, emergency room, doctor’s
office or other institution; employ any physicians, dentists, nurses, or other person whose services may be
needed for such health care; review and if necessary disclose the contents of any medical records; execute any
consent form required by medical, dental or other health authorities incident to the provision of medical,
surgical or dental care to the child. Health care shall include but not be limited to the administration of
anesthesia, X-ray examination, performance of operations, diagnostic and other procedures.
If there is no medical emergency, the guardian will first use reasonable efforts to contact the parent(s) and/or
guardian(s) before administering or authorizing any treatment.
Notwithstanding other provisions in this Consent Form, Organizer shall not have the authority to withhold or
withdraw life-sustaining procedures for the Child.
The undersigned assume(s) all risk of injury or harm to the Child associated with participation in the Activity
and agree(s) to releases, indemnify, defend and forever discharge the Organizer and its staff, employees and
agents (collectively the "Organizer") of and from all liability, claims, demands, damages, costs, expenses,
actions and causes of action (collectively the "Claims") in respect of death, injury, loss or damage to the Child
or by the Child, howsoever caused, arising or to arise by reason of or during the Child's participation in the

Signed on ________________ (date), at _______________________ (city), _______________ (state).

________________________________                             _____________________________
Signature of Parent/Guardian                                 Signature of Parent/Guardian

________________________________                             _____________________________
Printed Name of Parent/Guardian                              Printed Name of Parent/Guardian
                        Child Care Information and Instructions

Child's Name:

Allergic response signs and/or symptoms:

Child's Age:

                                 Parent(s) and Other Contacts

Mother’s Name:

Father’s Name:

Address of Parent(s):

Home#                                        Work#

Second Contact Name:
Relationship:                                Phone Number:

Third Contact Name:
Relationship:                                Phone Number:

                           Medical/Health/Insurance Care Information

Child’s Doctor Name:


Office Telephone:                            After Hours Number:

Health Insurance Company:

Group or Policy Number:

Telephone Number:

Shared By: