AWANA Registration PwrMail | Good Shepherd Baptist Church

AWANA Registration Information:

Please fill out the registration form below and submit. Come to the Kickoff / Hotdog Supper September 11 between 5 and 7 p.m. Go to the registration table and sign the registration form you have submitted. At that time you will be able to talk with teachers and purchase supplies for your child.

Save the dates:

Kickoff and Hot Dog Supper - 9/11 5-7 p.m.
1st Club night - 9/18 5-7 p.m.
Christmas VBS - 12/3
1st club night 2012 - 1/8
Easter Event - 4/7
Final Club Night - 4/29
AWANA Grand Prix - 5/4
Family Cookout/Awards - 5/5

Fields marked by * are required
Mouse-over information icon (i) for additional details

Child's Information

First Name (Child)*

Last Name (Child)*

Date of Birth (Child)

Format is MM-DD-YYYY (select using Calendar or type in directly)*

Gender (Child)*

Grade Completed

What is the last Grade that your child completed? (if in school)*

Does Child have experience with AWANA?

Has your child attended AWANA in the past? (at this Church or Another Church)

Parent's Information

Name (Parent)*

Email Address*

Primary Phone

Secondary Phone

Street Address

City

State

Zip

Contact Notes

Please enter additional Contact information in this area (Secondary Emails, Phone numbers, Physical Address (if different than Mailing Address), Availability times and dates, etc.)

Do you have a Home Church?

If "Yes", what church?

Emergency Contact

Emergency Contact Name

This should be someone OTHER THAN the parent listed above. (Contact will be attempted with Parent first)*

Emergency Contact Phone*

Emergency Contact Address

Persons Authorized to Pick up Child

Emergency Medical Authorization

I/we the parent(s)/guardian of this child authorize Good Shepherd Baptist Church to obtain immediate medical care and consents to the hospitalization of, the performance of necessary diagnostic test upon, the use of surgery on, and/or the administration of drugs to my/our child or ward if an emergency occurs when I/we cannot be located immediately. I/we also understand that this agreement covers only those situations that are true emergencies, and only when I/we expect to be contacted immediately. I/we will be responsible for payment of medical care expenses.

Discaimer Response

Do You agree with this Disclaimer*

Insurance Company Name

Insurance Policy Number

Child's Physician

Physician's Phone Number

Medical History

Asthma

Enter age at which child was first affected. Additional information can be provided in details section below.