2016 Awana Club Registration

Clubber's Information

Name

Phone

Address

Which Club?

Puggles (2-3 yrs.) Cubbies (4-5 yrs.) Sparks (K-2nd) T&T Adventure (3rd-4th) T&T Challenge (5th-6th)

Parent or Guardian Information

Name

Phone

Address

Emergency Contact/ Authorized for Clubber Pickup

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Name

Emergency Contact Phone number

Permissions

I give my permission for my child's picture to be taken and used for social media.

Yes No

Medical Release Information

As a parent/ guardian, I do hereby authorize the treatment by a qualified and licensed medical doctor of the above minor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his/ her life, cause disfigurement, or undue comfort if delayed. This authority is granted after all reasonable efforts have been made to reach me. I am agreeing to what is outlined in this release of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence for the Awana Club.

Medical Permissions

I grant permissions I do not grant permissions

Allergies/ Sensitivities

Food, Drug or other

Payment Information

Covers uniform, books, awards and end of year ceremony. Choose to pay online or in person.

Option

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

Please fill out this form and click submit.

2016 Awana Club Registration

Description

Please Fix the Following