2011-12 AWANA Registration

* Child's Full Name
* Child's Date of Birth
* Child's Age
* School Grade
* School Attending
* Parent/Guardian's Full Name
* Email
* Street Address
* City
* State
* Zip Code
Home phone
Work phone
Cell phone
Medical Conditions we should be aware of?
Custodial issues we should be aware of?
Anyone forbidden by court order to pick up your child? If so, who?
* Actively involved in a local church?
* Medical consent: In the event of a medical emergency, I give CBC and its representatives permission to seek medical attention for my child.
* If I am unable to be reached, I give CBC & its representatives permission to act in my stead until I can be notified.
  By entering my full name below, this serves as my electronic signature, verifying my consent that all information is correct and valid.
* Electronic Signature-enter full name of parent/guardian
 
The image below ONLY contains letters.


* Letters in image:  
 


*** You must have JavaScript enabled to use this form ***

RETURN TO THE CLEARWATER AWANA HOME PAGE