Awana Registration

Child's Name *

First

Last

Address *

City *

State *

Zip *

Parent/Guardian's Name *

First

Last

E-mail Address *

Home Phone # *

Cell Phone # *

Alternate Contact Name & Phone # *

School Grade Fall 2016 *

Church you attend regularly *

Special Needs/Concerns *

Authorization:
In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by First Baptist Church Maryville, MO to secure and administer treatment, including hospitalization, ambulance transport and paramedics for the person named above. I hereby agree to fully pay all costs of medical or dental care incurred by First Baptist Church Maryville, MO or their agent for the child under authorization.

Pictures and video may be taken during the event for church use.

Parent/Legal Guardian Signature: *

Date *

Submit