AWANA REGISTRATION

our cubbies and puggles clubs are full

AWANA REgistration 2019-2020

* Indicates required field

SELECT ONE *

NAME *

First

Last

ADDRESS *

EMAIL *

BIRTHDAY *

AGE *

SCHOOL *

GRADE *

FATHER/GUARDIAN'S NAME *

Phone Number *

Select One *

MOTHER/GUARDIAN'S NAME *

Phone Number *

Select One *

SIBLING(S) NAME AND AGE AND DO THEY ATTEND AWANA? *

Do you go to church? Where? *

May we communicate with you... (check all that apply) *

EMAIL PHONE text MAIL

IN CASE OF EMERGENCY, WHO MAY WE CONTACT? (List Name and Phone) *

TO ENSURE THE SAFETY OF YOUR CHILD, PLEASE LIST WHO IS AUTHORIZED TO PICK UP THIS CHILD (Besides the Parent/Guardians listed above) *

I (we) understand that, in the event medical treatment is required, every effort will be made to contact me. HOwever, if i cannot be reached, i give my permission to the staff or sponsor to secure the services of a licensed physician to provide the care necessary, including anesthesia, for my child's well-being.

SIGNED *

DATE *

NAME OF PEDIATRICIAN (And Phone) *

DATE OF LAST TETANUS SHOT *

PLEASE LIST ANY MEDICAL ALLERGIES, MEDICATIONS BEING TAKEN, MEDICAL PROBLEMS, OR OTHER PERTINENT INFORMATION AND SPECIAL NEEDS *

There is a cost to Awana (handbook, uniform, dues, etc.) Will you need any financial help? *

Planning to pay at Club Pay in installments Scholarship needed

We are so excited to have your student join us for Awana this year. If you have any questions, feel free to call the church office M-Th 9 am-3pm; or email us any time: info@fbcmedford.org

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AWANA REgistration 2019-2020

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