AWANA Registration

Child's Name *

First Name

Middle

Last Name

Address of Child

Address Line 1

Address Line 2

City

State

Postal Code

Birthday of Child

Grade of Child

Gender

Home Church

First Emergency Contact

First Emergency Contact Phone Number

Second Emergency Contact

Second Emergency Contact Phone Number

Parent or Guardian's Name

Relation to Child

Address of Parent or Guardian

Address Line 1

Address Line 2

City

State

Postal Code

Email Address of Parent or Guardian

Date

Specific Medical Information

How did you hear about AWANA?

Thank you for registering for AWANA! NOTE: Space may be limited. The AWANA commanders will attempt to confirm all registrations the first night. To whom it May Concern: As the parent or guardian, I do herewith authorize the treatment by a qualified and licensed medical doctor of the following minor in the event of a medical emergency which in the opinion of the attending physician may endanger the life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me. The undersigned does hereby release and agree to hold harmless Fremont Alliance Church, AWANA Clubs and AWANA Clubs International, and their directors, employees, agents, or representatives from any and all liabilities or claims for personal injury, illness or death, as well as property damage and expenses of any nature whatsoever which may be incurred by our (my) son/daughter that occur on the above date stated and/or while said child is participating in the above named camp program and its activities. This release is intended to be used during the entire year, September 2011 through May 2012. This includes both club meetings and outings (i.e. AWANA Games, Sparks-a-Rama, Club Hikes etc.) This release form is completed and signed of my own free will.

I have read and agree to the disclaimer* Yes
No