<p> ****** SECTION A – PARTICIPANT REGISTRATION & HEALTH ******</p><p>LAST NAME: ______(Use one form per last name. ++The back can be used for additional information or comments.)</p><p>First Name M/F Age Grade DOB ++Health Information (allergies, medications, chronic illness/conditions…)</p><p>Family Address: City:</p><p>State: Zip: Home Phone: Email:</p><p>++Emergency Contact & Phone: Cell Phone:</p><p>****** SECTION B – MEDICAL RELEASE ****** As a parent and/or guardian of the above named child/children, I authorize treatment by emergency personnel and/or a physician in the event of a medical emergency which, in the opinion of the physician, may endanger his/her life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted after reasonable effort was made to reach me and I was unavailable. Insurance company, ______, Policy number, ______Family Doctor: ______Phone: ______</p><p>I agree to take full financial responsibility for all medical services rendered to the above named participants and release AWANA Clubs International, its employees and its charters from this liability. This medical directive will be carried out by the Coordinator, Commander or other responsible adult.</p><p>****** SECTION C – PICK-UP RELEASE ****** To ensure the safety of our children, each child must be signed out at the end of every AWANA Club night by a parent or other authorized person. Please list below the names of those people and included your name.</p><p>First & Last Name First & Last Name</p><p>AUTHORIZATION OF PARENT OR GUARDIAN My signature serves to indicate my authorization/release for my child’s participation in AWANA Club (Section A), medical release (Section B) & pick up release (Section C) and will be in effect, August 26, 2015 through April 26, 2016.</p><p>Signature of parent/guardian Date</p><p>Print & complete this form to hand in at check-in www.mchenryefc.com * 2614 North Ringwood Road * McHenry, IL 60050 * 815.344.1111</p>