Parents' Name(s)           

Street Address 

City       State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY      Zip Code  

Home Phone:      Email:   

IN CASE OF EMERGENCY PLEASE CALL:

Name        Phone   

Persons (other than parents) authorized to pick up your child 

Child’s Name       Birthday    

Grade  Pre-K K-5 1 2 3 4 5   Age: 3 4 5 6 7 8 9 10 11 12

Registration Fee is $15 per child, but we would like all children to participate!
(please check one)

I can pay $15 per child  I can pay $10 per child

I can pay $5 per child    I need a full scholarship. 

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Terms and Conditions:

1. I understand that my child/children may participate in physical activities such as those held during Game time.  As with any physical activity, there is a risk of injury.  I fully accept this risk and hold harmless from any legal liability, Christ Community Church and any persons involved in the Awana Club ministry.
    
2. In the event of an emergency that requires medical treatment for the above names child/children, I understand ever effort will be made to contact me or my emergency contact.  However, if I/ we cannot be reached, I give my permission to the Awana volunteers to secure the services of a licensed physician to provide the care necessary for my child’s well being.  I assume responsibility for all cost connected to any accident of treatment of my child.
    
3. I grant permission for a photo of my child to appear in and unpublished club directory to be used by Awana leaders ONLY.  I also give permission for photo’s of my child to appear among other general club photos as long as there in no identifying information shown.

  I have read and agree to the Terms and Conditions above.