Parent /Guardian *

Primary Contact

First Name

Last Name

Parent/Guardian DOB

MM

DD

YYYY

Parent/Guardian Phone *

(###)

###

####

Parent/Guardian Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Spouse

First Name

Last Name

Spouse DOB

MM

DD

YYYY

Spouse Phone

(###)

###

####

Spouse Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Church Member? *

Check one

Yes

No

Persons (other than parents) authorized to pick up the children:

First Name

Last Name

Phone of Person (other than parents) authorized to pick up the children:

(###)

###

####

Child 1 *

First Name

Last Name

DOB Child 1

MM

DD

YYYY

Child 2

First Name

Last Name

DOB Child 2

MM

DD

YYYY

Child 3

First Name

Last Name

DOB Child 3

MM

DD

YYYY

Child 4

First Name

Last Name

DOB Child 4

MM

DD

YYYY

Doctor Name Child 1

Child 1

First Name

Last Name

Doctor's Phone Child 1

(###)

###

####

Doctor Name Child 2

Child 2

First Name

Last Name

Doctor's Phone Child 2

(###)

###

####

Doctor Name Child 3

Child 3

First Name

Last Name

Doctor's Phone Child 3

(###)

###

####

Doctor Name Child 4

Child 4

First Name

Last Name

Doctor's Phone Child 4

(###)

###

####

Terms and Conditions *

1)I understand that my child/children may participate in physical activities such as those held during Time. As with any physical activity, there is a risk of injury. I fully accept this risk and hold harmless from any legal liability, Congregation Lion of Judah and any persons involved in the Awana Club ministry. 2)In the event of an emergency that requires medical treatment for the above named child/children, understand every effort will be made to contact me or my emergency contact. However, if I/we cannot be reached, I give my permission to the AWANA volunteers to secure the services of a licensed physician to provide the care necessary for my child's well being. I assume responsibility for all costs connected to any accident or treatment of my child. 3)I give permission for my child's photo/video to be used in variety of publications and news programs.Received Registration Fee of $15 is Non-Refundable if unable to attend the club.

Accept