WELLSPRING BIBLE FELLOWSHIP

AWANA CLUB, ROSEBURG, OR.

Name of Child ___________________________________________________________________________________
Childs Address______________________________________________City, State, Zip________________________
Parents Home Phone_________________________Parents Cell Phone_______________________________
Phone number of where primary responsible adult/parent can be reached on Wednesday
Night:________________________________________________
Childs Birthdate__________________________________Age:___________Grade:_____________
Childs Home Church_____________________________________________________________________________
Childs Parents(s) or Guardians(s)____________________________________________________________________
Parents email address_________________________________________________________

MEDICAL AND LIABILITY RELEASE FORM:

FORM:
To Whom It May Concern:
As a parent and/ or guardian, I authorize the treatment of the following minor by a qualified and licensed medical
doctor in the event of a medical emergency which, in the opinion of the attending physician, may endanger this
minors 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.
Name of Minor Child__________________________________________________Male or Female___________
Family Physician_____________________________________________Phone Number_________________
Date of Last Tetanus Shot___________________________

ALTERNATIVE PERSON TO CONTACT IN THE CASE OF AN EMERGENCY:

EMERGENCY:
Name___________________________________________________Phone Number_______________________
Specific medical allergies, chronic illnesses, or any other conditions
_______________________________________________________________________________________________
This release form is completed and signed of my own free will with the sole purpose of authorizing medical
treatment under emergency circumstances in my absence. By signing this form, I agree to assume and accept all
risks and hazards inherent in church related social activities. I also agree not to hold this church or its employees
or volunteer assistants liable for damages, losses, or injuries to the person or property above mentioned.
Signed____________________________________(Parent/Guardian)Phone_______________Date______________
Our churchs insurance is only secondary insurance. If you have medical insurance, your carrier will be billed for
medical charges in the case of illness or injury while your minor is on a church related activity.
Name of your Insurance Company___________________________________________________________________
Policy Number_________________________and/or I.D. Number_________________________________________
Name of Principle Person Insured___________________________________________________________________