Important Note: We ask that you also stop by the registration table & sign the registration form. This is an extra step to ensure a parent or guardian actually submitted the registration.

Registration night: August 30th at 6:30
1st night of Awana: Sept. 6th 6:30-8:15 pm

This registration is valid from September 2017 to May 2018

Child's Information

Child's Name:

Child's Date of Birth:

Child's Age:

Child's Grade - Fall 2017:

Choose One:
 Boy Girl

Address:

City:

Zip:

Home Church:

Parent / Guardian Information

Parent(s) / Guardian(s) Name:

Primary Phone:

Secondary Phone:

Email:

Alternate / Emergency Contact Information

Alternate Contact Name:

Alternate Contact Primary Phone:

Alternate Contact Secondary Phone:

Additional Helpful Information

Information which may require special attention (including any helpful suggestions)

Allergies:

Medical:

Physical:

Emotional:

Behavioral:

Miscellaneous Info:

To Whom It May Concern:
As a parent and/or guardian, I authorize the treatment by a qualified and licensed medical doctor of this minor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her 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.

This release form is completed and signed of my own free will with the sole purpose of giving permission for my child to participate in the AWANA program and for authorizing medical treatment under emergency circumstances in my absence.

Signature: Start and End your name with a /
Example: /Betty Smith/

Date:

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