Awana Child Registration Form

Because Kids Matter to God!
Awana Child Registration

Open to Children, 2 Years Old - 6th Grade
Child Information
Child's Name*

First NameLast Name
Age *
Birth Date*

MonthDayYear
Gender*

MaleFemale
Please Upload a recent photo of your child, we can use to identify him/her (close up ID type photo of full face and shoulders)
Address (where the child resides)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Home Number
Cell Number*
Secondary Cell Number
E-mail*
example@example.com
Emergency Information

(if unable to reach parent/guardian)
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number
Insurance
Insurance Policy/Group #
Doctor/ Clinic/ Hospital
Doctor/ Clinic/ Hospital Phone Number
Does the child have any allergies, food allergies, chronic illness, medical conditions, or special needs we should be aware of? If yes, please describe.*
Does the child or family have a "home church" where they attend 3 or more times per month? If yes, please include the name and location of your church.*
How is the Child getting to and from Awana? Are there any special instructions we should know about?*
Please list any siblings that are also attending Awana and their ages*
All Children must be registered individually and have their own registration
Medical Release and Authorization

(Effective Sept 1, 2024-Aug. 31, 2025)

I hereby give my permission to the physician or dentist selected by New Life Church of the Nazarene, Wheeler, Wisconsin, to hospitalize, to secure proper treatment and/or order an injection, anesthesia or surgery for my child(ren) as
deemed necessary, after every attempt to contact the parent, guardian and/or other emergency contact has failed.

I further agree that I am fully responsible to pay all charges and expenses relating
to such care and treatment. My signature below serves to indicate my willingness for my Health Insurance Company to be billed for any and all medical fees and services should they be needed. I agree that I will pay all charges and expenses not covered by my insurance. My signature below also serves as a medical release for the above mentioned child(ren).
Permission:

I hereby give consent for the above named child(ren) to participate in extracurricular Awana activities during the current club year. I further agree to hold harmless New Life Church of the Nazarene, Wheeler, Wisconsin, Awana Volunteers, and/or Awana Clubs International should injury occur during events sponsored by said church or Awana Clubs International. This permission also includes transportation when provided with qualified vehicles and drivers.
Photography/ Video Permission:
We may occasionally photograph or videotape the exciting events and activities that children experience at New Life Church of the Nazarene Awana Clubs. Please consider allowing photos or videotape in which your child may appear to be published in NLCN Awana Clubs newsletters and/or publications or on our NLCN website.

Yes, I give permission for photographs and/or video of my child to be published and/or posted as described above.No, photographs and/or video of my child may NOT be published and/or posted as described above.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date*

MonthDayYear
Date
Signature*

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Because Kids Matter to God!

Awana Child Registration

Child Information

Emergency Information

Photography/ Video Permission: