1st Child *
1st Child
Birthday *
Birthday
2nd Child
2nd Child
Birthday
Birthday
3rd Child
3rd Child
Birthday
Birthday
4th Child
4th Child
Birthday
Birthday
5th Child
5th Child
Birthday
Birthday
Address *
Address
Parents or Guardian *
Parents or Guardian
Best Phone No. *
Best Phone No.
Emergency Contact *
Emergency Contact
Emergency Contact Phone *
Emergency Contact Phone
The emergency contact will be contacted in the event that parent/guardian cannot be reached
By entering my name in the blank below I am giving permission to attend Brownsburg Baptist Church Master Clubs during 2016-2017 School Year and participate in all activities associated with Master Clubs. As the parent/gaurdian, I do hereby authorize treatment under the direction of any licensed physician or emergency medical personnel, of the above minor child in the event of a medical emergency. This authority is granted only after reasonable effort has been made to reach me by phone at the phone numbers listed above. The undersigned assumes the responsibility for any costs connected with such treatment and hereby releases Brownsburg Baptist Church from any liability thereof. This release for is completed and signed of my own free will with the sole purpose of authorizing participation in Master Clubs for the period of August 6th, 2014 through May, 2016 and medical treatment in emergency circumstances in my absence.