Form

Awana 2010-2011 Registration Form
Parent's /Guardian's Name:*
First Name Last Name

Address:*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number:*
- Area Code Phone Number
Alternative Phone Number:*
- Area Code Phone Number
Emergency Pickup Person:*
First Name Last Name
Emergency Pickup Person Phone Number:*
- Area Code Phone Number
Relationship of Emergency Pickup Person to Clubber:*
First Child's Name:*
First Name Last Name
Male/Female:*

Male Female
Grade in School:*
Birth Date:*
Month Day Year
Age:
I have more children to register

Yes No

Second Child's Name:*
First Name Last Name
Male/Female:*

Male Female
Grade in School*
Birth Date:*
Month Day Year
Age
I have more children to register

Yes No

Third Child's Name:*
First Name Last Name
Male/Female:*

Male Female
Grade in School*
Birth Date:*
Month Day Year
Age
I have more children to register

Yes No

Fourth Child's Name:*
First Name Last Name
Male/Female:*

Male Female
Male/Female:*

Male Female
Grade in School*
Birth Date:*
Month Day Year
Age
I have more children to register

Yes No

Fifth Child's Name:*
First Name Last Name
Male/Female:*

Male Female
Grade in School*
Birth Date:*
Month Day Year
Age
I have more children to register

Yes No

Sixth Child's Name:*
First Name Last Name
Male/Female:*

Male Female
Grade in School*
Birth Date:*
Month Day Year
Age

I hereby authorize AWANA leaders to administer first aid and to obtain and consent to on my behalf any emergency first aid or medical care by any physician or hospital for my child(ren) listed above. I agree to abide and be bound by such consents as if made by me. I further authorize any physician, hospital or medical attendant to receive full and complete medical reports or information deemed necessary with respect to the treatment of my child(ren) listed above. I understand the leadership of the AWANA will make every attempt to contact me in the case of an emergency. Execution of this document shall operate as an authorization for such person(s) to receive any medical information which they require.
Click this button to consent to the above statement.*

I consent to the above listed medical authorization statement.
My payment choice*

I will bring my payment to Calvary Baptist Church. I would like to pay now using my PayPal account or credit card

Registration fees
Cubbie Registration $35.00 USD

Quantity
Sparks Registration $40.00 USD

Quantity
T & T Registration $40.00 USD

Quantity
TREK Registration $40.00 USD

Quantity

Total: $0.00 USD

Should be Empty: