Registration Date (required) - (mm/dd/yyyy)

Last Name (required)

First name (required)

Gender FemaleMale

Child's Grade Fall 2018 (required)

Child's DOB (required) - (mm/dd/yyyy)

Home Address (required)

City (required)

State (required)

Zip Code (required)

Allergies & Medical Cautions

Reaction to the Allergy

Parent Name

Parent Work #

Parent Cell #

Parent E-mail Address (required)

My child is a (required)

non swimmerwaderadvance swimmer

Person Registering (required)

Adult LeaderTeen LeaderChild

Emergency Contact Name (required)

Phone #(required)

Relationship (required)

Date of last Tetanus Shot


Medication Taken Regularly


T-Shirt Size (required)


Parent Authorization/ Medical Release

I understand every effort will be made to notify me in the event of an emergency. If, however, I cannot be reached and such becomes necessary, I hereby grant permission to the physician selected by the adult in charge of First Baptist’s AWANA Summer Camp to hospitalize and secure proper treatment for my son/daughter named below. Furthermore, I release the camp leaders, FBCHP, and the Refreshing Mountain Camp from any liabilities in connection with this emergency.

Child's Name

Insurance Company Name

Policy #

Insurance Company’s Telephone #

Name Policy is Under

Parent/Guardian’s Electronic Signature (required)