Awana Registration

CHILD'S NAME: (required)

CHILD'S AGE: (required)

CHILD'S DATE OF BIRTH: (required)

CURRENT GRADE: (required)

PARENT/LEGAL GUARDIAN NAME - primary contact: (required)

YOUR PHYSICAL ADDRESS: (required)

MAILING ADDRESS if different:

HOME PHONE: (required)

CELL PHONE:

YOUR EMAIL:

PARENT/LEGAL GUARDIAN NAME - secondary contact:

HOME PHONE #2: (if different than above)

CELL PHONE #2:

Do you have a HOME CHURCH? If so, where?

CONSENT TO MEDICAL TREATMENT: I hereby give my consent for my child to receive medical treatment that may be deemed advisable in the event of injury, accident and/or illness during the club year. (reqiured)
Check to indicate your consent

MEDICAL INFORMATION we need to know. Please include food allergies. Enter "None" if there are none.(required)

Will your child be under any MEDICATIONS while at Awana? If yes please provide details. Enter "None" if there are none.(required)

Date of LAST TETNUS SHOT (required)

DOCTOR'S NAME (required)

DOCTOR'S PHONE NUMBER (required)

INSURANCE PROVIDER

INSURANCE POLICY NUMBER

INSURANCE GROUP NUMBER

INSURANCE COMPANY ADDRESS

EMERGENCY CONTACT #1 NAME: (other than listed above) (required)

Your EMERGENCY CONTACT #1 PHONE #: (required)

EMERGENCY CONTACT #2 NAME: (other than listed above)

EMERGENCY CONTACT #2 PHONE #:

DISMISSAL INFORMATION: I understand that my child must be personally checked in and out each week!
Who may pick up your child at the end of each AWANA event(required)

OTHER INFORMATION:

MEDIA RELEASE: I understand that a 1st Baptist Church Awana activities and events, my child may be photographed. I agree to allow my child's photo, video or film likeness to be used for any legitimate purpose by the church. When an identification is made, only the first name of the child may be used along with the name of the church.(required)
Check here to indicate my agreement.

AWANA CONTACT PERMISSION: Occasionally an Awana volunteer may like to contact you and your child to see how they are enjoying the club and if they need help in completing their handbooks. An Awana volunteer may also like to send written correspondence such as a get well card, birthday card or an email when appropriate.(required)
Check here to indicate that you give your permission.

DUES: Dues are $50. Checks are payable to: First Baptist Church of Carson City. Please mark "for Awana". They can be mailed to - 1750 N. Mountain St., Carson City, NV 89703. This pays for uniforms, books, awards and some special events. Please indicate how you will be paying: (required)
Mailing check nowPay at the 1st meetingI need to make paymentsI am unable to pay and request a scholarship

RELEASE OF LIABILITY: I state that my child is fully capable of safely participating in all activities and I expressly assume all risks of my child’s involvement, whether such risks are known or unknown to me at this time arising from transportation related activities, recreational and extra curricular activities, accidents, adverse weather conditions and injuries and illness as a result of food borne illness and allergic reactions. I further generally release First Baptist Church volunteers and other participants from any and all claims that I or my child may have against any of them. This Release of Liability is given on behalf of myself and my child during the current club year. (required)
Check here to indicate your acceptance of this Parental Consent and Release of Liability Statement

AUTHORITY TO SIGN: I represent and warrant that I am the parent or legal guardian of the child named above and have the full power and authority to enter into this Parental Consent and Release of Liability on behalf of my child. (required)
Check here to indicate that you acknowledge and understand this document and also represent that all information provided is accurate.

UNIFORM SIZE: for 3rd graders and up (leave growing room).
(select one) Youth Size 14Youth Size 16Adult SmallAdult Med.Adult LargeAdult XL

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