pic AWANA REGISTRATION

Clubber Information


Name: Age: Date of Birth:
Address:

Parent/Guardian:
Home Phone: Work Phone: Cell Phone:
E-mail Address: Church Home:

Friend of: School: Grade:


Emergency Contact


Name: Phone:
Address:


Medical Information


Physician Name: Phone:
Health Insurance Company: Policy/Group#:
Policy Holder: Employer:

Specific medical allergies, chronic illnesses, or other conditions:

Present medications: Date of last tetanus shot:


Liability / Medical Release


I have read and agree to the liability / medical release and all sections therein.
Agreed to by Date: