Register for AWANA! | Brillion CC

AWANA Club Registration/Activity Permit

Please register one child per form.

To Whom It May Concern: As a parent and/or guardian, I do herewith authorize treatment under the direction of any licensed physician of a medical emergency which, in the opinion of the attending physician, may endanger my child's 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 by phone at the number(s) listed below.

Child's Name

Birthday

Age

Grade

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 absences.

Signed

Address

Please provide at least one phone number.

Phone (Primary)

Phone (Secondary)

Church You Attend

Family Physician

Health Insurance Name

Physician Phone

Health Insurance Phone

Specific medical allergies, chronic illnesses, or other conditions:

Date of last tetanus shot:

Other contact(s) in case of emergency:

Approved Contact Name

Approved Contact Phone

The Following People May Pickup My Child

Pictures of my child may be taken for use at AWANA (not required)

Pictures may be published in local publications (i.e. "The Brillion News") (not required)

Thank you for registering your child for AWANA for the 2022-2023 club year! See you on Wednesday, September 14th at 6:30 P.M.

AWANA Club Registration/Activity Permit

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