Clubber Information
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
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Gender
Please Select
Male
Female
Email Address
Phone Number
Please enter a valid phone number.
Grade
Have you previously attended this Awana club?
Yes
No
If yes, what year?
Primary Residence Information
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Residence Information (if different from above)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Emergency Contact
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.
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Notes
Please inform us of any other vital information you think we may need to know in the event of an emergency. Thank you.
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