FBC of Lowell 2017-2018 Awana Registration Form
Awana meets at FBC Lowell, Wednesday nights from 6:15-8:00.
Child's Information
Child's First Name:
Your answer
Child's Last Name
Your answer
Gender:
Birth Date (month/date/year):
Your answer
Home Phone Number:
Your answer
Cell Phone Number:
Your answer
Parent/Guardian Name(s):
Your answer
Street Address:
Your answer
City:
Your answer
State:
Your answer
Zip Code:
Your answer
Grade in 2017-2018 School Year:
Age:
Your answer
Church your child attends:
Your answer
Current Active Contact Email Address:
Your answer
Emergency Contact Information
FBC of Lowell, in the event of an emergency will try to contact the parents; but in the event that we cannot reach you, is there another non-parent responsible adult that you would authorize us to contact? List that person's information on the emergency contact line below
Emergency Contact Name:
Your answer
Emergency Contact Phone Number:
Your answer
For the safety of your child, we will only release your child to:
FBC Lowell cannot always assume that it is alright to release a child to both of their parents, so please include parent's names and any other responsible individual you will allow us to release your child to.
1.) Name (First and Last)
Your answer
Phone Number
Your answer
2.) Name (First and Last)
Your answer
Phone Number
Your answer
3.) Name (First and Last)
Your answer
Phone Number
Your answer
Medical/Health Insurance Information
Do you have insurance?
Company
Your answer
Group #
Your answer
Policy #
Your answer
Policy Holder
Your answer
Family Doctor
Your answer
When was your child's most recent tetanus shot?
Your answer
Please list any medications your child takes.
Your answer
Please list any allergies or other medical conditions we need to know about.
Your answer
Please list any other information you feel may be helpful in seeking medical treatment for your child:
Your answer
Will your child need transportation?
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