AWANA Clubber Registration
Club Year: 2019-2020
Date Form Filled Out *
MM
/
DD
/
YYYY
Child's First and Last Name/Nickname *
Full Birthdate *
MM
/
DD
/
YYYY
Gender *
Grade Entering/School Name *
Parent/Guardian Name(s) *
Full Address (include city, state, zip) *
Home Church *
Persons (other than parents) authorized to pick-up the child(ren): *
Home Phone/Contact Person (i.e. 123-456-7891/John Doe) *
Work Phone/Contact Person *
Cell Phone/Contact Person *
Email/Contact Person *
Other #/Contact Person *
Emergency #/Contact Person (during club time other than parents): *
Doctor Name and Phone *
Dentist Name and Phone *
Allergies/Medications/Special Needs *
I Am Interested in Helping (Note: all AWANA Club leaders and listeners must submit to a background check before working with the children):
Terms and Conditions
I have read and agree to the Terms and Conditions stated above (Sign Name/Date): *
Submit
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