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Autumn Creek Baptist Church AWANA Club Registration
Fill this out to register for the Autumn Creek Baptist AWANA Club.
Child's Full Name
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Child's Address
Street number and name, city, and zip code please.
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Date of Birth
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Grade
Do you belong to a church?
If so, which one?
Your answer
Parent Name
Your answer
Parent Cell Number
Your answer
Parent Work Number
Your answer
Second Parent Name
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Second Parent Cell Number
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Second Parent Work Number
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Emergency Contact Name
The individual listed below may be contacted if the above named child becomes ill or injured and the parent or guardian cannot be reached. These individuals may also be contacted in the event my child must be picked up from a club meeting due to behavior if I am unable to be reached.
Your answer
Emergency Contact Relationship To Child
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Emergency Contact Cell Number
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Secondary Emergency Contact Name
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Secondary Emergency Relationship To Child
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Secondary Emergency Cell Number
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Primary Doctor
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Doctor's Phone Number
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Serious Medical Problems
List any Allergies as well.
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Does your child take any medications?
If yes, please list the name, dose, and time taken.
Your answer
Insurance Policy Holder
Your answer
Name of Policy
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I agree to the following:
I give Autumn Creek Baptist Church permission to seek medical attention for my child in the event of illness or injury, if I or any above named persons are unable to be reached. I will not gold Autumn Creek Baptist Church or its representatives liable in the event of injury to my child. My child has permission to participate in AWANA games, activities, and snack time. If my child has any allergies, I have stated those allergies in this document. I understand that if my child is behaving in a non-Christian manner, he or she will be removed from the AWANA Club and remain with the person in charge for the rest of that session or be picked up by a parent. I understand that this will only affect my child for that session and that he or she is welcome to return to AWANA Club the following club night. I understand that for the safety of my child he or she must wear tennis shoes to participate in game time
I give permission to Autumn Creek Baptist Church for my child's photo, video, image, and/or artwork to be displayed at the church or on the church website.
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