Child’s Name______________________________________ Birth Date______________ Grade ________________

Address_____________________________________ City____________________   State ______    Zip _________

Parent/Guardian’s Name(s)___________________________________________________________________________

Phone __________________________________________   Cell______________________________________

E-Mail Address___________________________________

Name(s) of siblings at First Baptist_______________________________________________________________________

Are you a member at First Baptist Church? Yes______ No______

If no, what church do you attend? ____________________________________________________________________

May we send you information about our church? Yes______ No______

May we have permission to photograph your child? Yes______ No______

May we have permission to use your child’s photograph in church publications for the purpose of promotion? Yes____ No_____

May we have permission to call, email, visit or send birthday/absentee cards to your child? Yes____ No_____

Medical Information/Permission for Treatment

Allergies________________________________________________                Doctor___________________________

Medications____________________________________________   Drs. Phone________________________

Emergency Contact ____________________________________       Emergency Number_______________

Health Care Company__________________________________        Policy Number ____________________

To whom it may concern: the undersigned does herby give permission for our (my) child, _________________________________,

to attend and participate in Awana, sponsored by First Baptist Church Myrtle Beach , 500 4^th Ave.

WE (I) authorize an adult, in whose care the minor has been entrusted, to consent to any x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care to be rendered to the minor under general or special supervision and on the advice of any physician or dentist licensed in SC or in any other state wherein the minor is then located, and who is on the medical staff of a licensed hospital in that state, whether diagnosis or treatment is rendered at the office of said physician/dentist or at said hospital. 

Date _________________________________

Name of Parent/Guardian(please print) _________________________________         Witness:____________________                             
Signature of Parent/Guardian_________________________________________