Awana Registration

Identification

Child's First Name(required)

Child's Last Name(required)

Street Address(required)

City(required)

State(required)

Zip Code(required)

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

Church Information

Church

Church Address

Father’s Information

Father's First Name(required)

Father's Last Name(required)

Cell Phone (father)(required)

Email (father)(required)

Mother’s Information

Mother's First Name(required)

Mother's Last Name(required)

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

Email (mother)(required)

Medical Information

Child's Physician(required)

Physicians's Phone(required)

Date of Last Tetanus Shot (MM/YYYY)(required)

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 (###-###-####)(required)

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

Parental Consent

(required)

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