Awana Registration

Identification

Child's First Name

Child's Last Name

Street Address

City

State

Zip Code

Home Phone (###-###-####)

Church Information

Church

Church Address

Father’s Information

Father's First Name

Father's Last Name

Cell Phone (father)

Email (father)

Mother’s Information

Mother's First Name

Mother's Last Name

Cell Phone (mother) (###-###-####)

Email (mother)

Medical Information

Child's Physician

Physicians's Phone

Date of Last Tetanus Shot (MM/YYYY)

If the child has allergies, please describe allergens, types of allergic reactions, and treatments.

If the child has pre-existing conditions, please describe.

If the child takes medications, please describe.

If the child has specific medical restrictions, please describe.

Emergency Contact Phone Number (###-###-####)

Parental Consent

Note:?Clubbers must also bring a signed parental consent form to Awana Clubs. Parental consent forms will also be available at the secretary’s table during check-in.

Awana Registration

Identification

Church Information

Father’s Information

Mother’s Information

Medical Information

Parental Consent

570.387.0655

cbcofbloom@gmail.com

English Language Club

3-on-3 Basketball Tournament

Camp Calvary

Awana

Awana Registration

Identification

Church Information

Father’s Information

Mother’s Information

Medical Information

Parental Consent

Search the site:

570.387.0655

cbcofbloom@gmail.com

English Language Club

3-on-3 Basketball Tournament

Camp Calvary

Awana