AWANA Registration Form
Number of Children Registering
*
Please Select
1
2
3
4
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Elementary Grade/Preschool Age
*
Please Select
2 years old
3 years old
4 years old
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
Any Allergies, Medical Conditions or Special Needs?
*
Yes
No
Please give details
2nd Child
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Elementary Grade/Preschool Age
*
Please Select
2 years old
3 years old
4 years old
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
Any Allergies, Medical Conditions or Special Needs?
*
Yes
No
Please give details
3rd Child
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Elementary Grade/Preschool Age
*
Please Select
2 years old
3 years old
4 years old
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
Any Allergies, Medical Conditions or Special Needs?
*
Yes
No
Please give details
4th Child
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Elementary Grade/Preschool Age
*
Please Select
2 years old
3 years old
4 years old
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
Any Allergies, Medical Conditions or Special Needs?
*
Yes
No
Please give details
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Next
Parent/Guardian Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Where will you be while your child(ren) is/are attending AWANA?
*
Emergency Contact Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
I, undersigned, agree with the following statements:
*
I am the parent/guardian of the child indicated above.
I give permission for my child to participate in AWANA activities.
If emergency medical care is needed and I am unavailable, I authorize Mount Hebron M.B.C (MHMBC) to seek medical treatment for my child. MHMBC, it's employees or volunteers will not be held liable for any accident, injury, or disease incurred by my child
I am giving my permission to take my child's pictures or video and post them on the church website or social media.
Date
*
-
Month
-
Day
Year
Date
Signature
*
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