AWANA REGISTRATION

AWANA REgistration 2018-2019

* Indicates required field

SELECT ONE *

NAME *

First

Last

ADDRESS *

EMAIL *

BIRTHDAY *

AGE *

SCHOOL *

GRADE *

FATHER/GUARDIAN'S NAME *

Phone Number *

home church *

MOTHER/GUARDIAN'S NAME *

Phone Number *

home church *

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

WHAT IS THE BEST WAY TO COMMUNICATE WITH YOU? *

EMAIL PHONE 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 *

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AWANA REgistration 2018-2019

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