• • First Child's Name *
    
    First
    
    Last
• • Age *
    
    
• • Grade Entering *
    
    
• • Specific medical allergies, chronic illness or other conditions:
    
    
• • Second Child's Name
    
    First
    
    Last
• • Age
    
    
• • Grade Entering
    
    
• • Specific medical allergies, chronic illness or other conditions:
    
    
• • Third Child's Name
    
    First
    
    Last
• • Age
    
    
• • Grade Entering
    
    
• • Specific medical allergies, chronic illness or other conditions:
    
    
• • Fourth Child's Name
    
    First
    
    Last
• • Age
    
    
• • Grade Entering
    
    
• • Specific medical allergies, chronic illness or other conditions:
    
    
• • Please Check All That Apply *
    Member of Capitol City Baptist Church
    Regular Attender of Capitol City Baptist Church
    New Guest to Capitol City Baptist Church
    Cap City Fitness Member
    New Resident to Des Moines Area
    I would like more info about Capitol City Baptist Church
    
• • Father's Name
    
    First
    
    Last
• • Phone Number
    
    
    
    
    
    
• • Mother's Name
    
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    Last
• • Phone Number
    
    
    
    
    
    
• • Address *
    
    Street Address
    
    Other Address (optional)
    
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• • AWANA Club Activity Permit

    As a parent/guardian, I do herewith authorize treatment under the direction of any licensed physician of the above named minor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, 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 listed. As the guardian, I assume responsiblility for any costs connected with such treatment and hereby release the church where the child attends AWANA from any liability therefore. Dates when release is intended: August 2012 through May 2013.
• • This release form is completed of my own free will with the purpose of authorizing medical treatment under emergency circumstances in my absence: *
    Yes
    
• • Guardian's Name *
    
    First
    
    Last

NOTE: Do Not Alter These Fields: