New Submission - AWANA Registration

Clubber's Name

Address

Date of Birth

Grade

Parent/Guardian Information

Parent's Name

This address will receive a confirmation email

Phone

Church Information

Are you a church member?

Church Name

Allergies/Medical Concerns

Any Allergies Your Child Might Have

Please List Any Medical Concerns That May Affect Your Child During AWANA (ex. asthma, seizures...)

Emergency Contact Information

Name

Relationship to Child

Phone

Dismissal Information

The adults listed below are authorized to pick up my child. (Adults other than parent/guardians).

SPBC Release

I, the parent/guardian listed above, grant SPBC permission to use my child's name, photos, audio recordings, and DVD's made at any SPBC event for the purpose of publicity, promotional materials, and website content.

Check the box below to either agree or disagree to the Marketing Release

I Agree I Disagree

Parent/Guardian Name

Date

Description

Please fill out this form and click submit.