Parkview Baptist Church

Participant Information

Participant Last Name *

Participant First Name *

Age *

Grade in School Fall 2024 *

Date of Birth *

T-shirt size *

Parent/Legal Guardian Information

*Note: This contact information will be used in the case of an emergency.*

Parent/Legal Guardian Name *

Relationship To Participant *

Home Phone Number *

Work Phone Number

Cell Phone Number *

Cell Phone Carrier *

Email

Street Address *

City *

State *

Zip Code *

Medical Profile

Generally, the participant's health is: *

Please explain the participant’s condition:

List any medical difficulties for which the participant is being treated:

Please Explain:

List any medicines or substances to which the participant is allergic: *

List any medications the participant takes:

List any special diets or needs:

Date of last tetanus immunization

Family Physician

Phone Number

Insurance Company

Phone Number

Subscriber Name

Subscriber Number

Place of Employment

Phone Number

Subscriber Occupation

Permission for Medical Treatment, Photograph/Video Notice and Release and Indemnity

My permission is granted for the camp or event director, church official, any camp or event staffer, or adult present or in charge of First Aid to obtain necessary medical attention in case of sickness or injury to my child. Also, I understand that as a participant, my child may be photographed or videotaped during normal camp or event activities and these photos/videos may be used in promotional materials. I, the undersigned, do hereby verify that the above information is correct and I do hereby release and forever discharge Parkview Baptist Church from any and all claims, demands, actions or causes of action, past, present or future, arising out of any damage or injury while participating in this camp.

I agree *

I Agree

Awana registration is now open! Awana kickoff Sunday will be held September 8th from 4:30-6pm.

Registration is open for Pre K – 5th Grade.

Participant Information

Parent/Legal Guardian Information

Medical Profile

Permission for Medical Treatment, Photograph/Video Notice and Release and Indemnity