Awana Registration

AWANA REGISTRATION

child information

* Indicates required field

Child's Name *

First

Last

Date of Birth (Day/Month/Year) *

Grade *

Child #2 Name (If Applicable) *

First

Last

Date of Birth (Day/Month/Year) *

Grade *

Child #3 Name (If Applicable) *

First

Last

Date of Birth (Day/Month/Year) *

Grade *

Child #4 Name (If Applicable) *

First

Last

Date of Birth (Day/Month/Year) *

Grade *

If you have more than four children, fill out this form and then resubmit a second form.

family information

Parent's Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

medical information

Allergies *

Insurance Company *

Medications Taken *

Plan Number *

emergency contact information

In Case of Emergency, Contact: *

Relationship to Child *

Home Phone Number *

Cell Phone Number *

Do you text? *

Yes No

release and waiver

My child has my permission to participate in all Grace Baptist Church activities on the church premises and in all off-site activities. In the event my child becomes ill or injured, I authorize the following actions:

Contact me first.
If I am not available, Grace Baptist Church personnel may use their judgment in contacting a qualified, licensed physician and following his/her directions.
In case my child is involved in an accident and requires treatment, the attending physician has my permission to examine my child and begin treatment in my absence. I grant this permission only after a reasonable effort has been made to contact me.

I understand that all expenses for medical treatment are my responsibility and that my insurance will provide the primary insurance coverage for my child. I agree not to hold Grace Baptist Church of Havana, IL, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by my child.

Typing my name below indicates my agreement to the above statements:

Parent/Legal Guardian Signature *

Today's Date *

Submit