Awana Registration Form
PCC Awana 2018-2019

The Club will meet on Wednesday evenings from 6:00pm to 7:30pm
Club begins: September 12

Untitled Title
Please select which Club your child will participate in at Awana:
Awana volunteers' children are given registration preference.
Choose Club: *
Child Information
Child's First Name *
Your answer
Child's Last Name *
Your answer
Child's Grade (2018-2019 School Year) *
Child's Birthdate *
Note: Please double-check that you have entered the correct year.
MM
/
DD
/
YYYY
Child's Gender *
Address
Address Line 1: *
Your answer
Address Line 2:
Your answer
City: *
Your answer
State: *
Your answer
Zip Code *
Your answer
Home Church
Your answer
Medical History
Preexisting or present medical conditions: *
Please describe any preexisting or present medical conditions we should be aware of. If none, answer "N/A"
Your answer
Medication your child is currently taking: *
If none, answer "N/A"
Your answer
General allergies or medication allergies: *
Please list any allergies that your child has. If none, answer "N/A"
Your answer
Does your child require the assistance of an aide in a classroom setting? *
If not, answer "N/A"
Your answer
Insurance Company *
Your answer
Policy # *
Your answer
Primary Care Physician *
Your answer
Primary Care Physician Phone # *
Your answer
Parent's Information
Parents'/Guardians' Names (First and Last) *
Your answer
Primary Email *
Your answer
Secondary Email
Your answer
Primary Phone# *
Include the area code, and type the digits only
Your answer
Secondary Phone# *
Include the area code, and type the digits only
Your answer
Other adults/siblings authorized to pick up my child:
Your answer
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