Name: Awana Clubs (2022-23)
Start: 2022-09-28T18:30:00+00:00
End: 2022-09-28T20:00:00+00:00
Location: Erieside Church

Register up to 3 children

How many children are you registering for Awana?*

1
2
3

CHILD #1 NAME*

First Last

Gender*

Male
Female

Date of Birth*

Grade in School*

Cubbies Vest Size

Please note sizes of Cubbies Vest Sizes in parentheses for most accurate fit.

Sparks Vest Size

Please note sizes of Sparks Vest Sizes in parentheses for most accurate fit.

T&T Shirt Size

Please note sizes of T&T Shirt Sizes in parentheses for most accurate fit.

Allergies & Medical/Chronic Issues (if any)

Current Medications (if any)

Child #2 Information

CHILD #2 NAME

First Last

Gender

Male
Female

Date of Birth

Grade in School

Cubbies Vest Size

Please note sizes of Cubbies Vest Sizes in parentheses for most accurate fit.

Sparks Vest Size

Please note sizes of Sparks Vest Sizes in parentheses for most accurate fit.

T&T Shirt Size

Please note sizes of T&T Shirt Sizes in parentheses for most accurate fit.

Allergies & Medical/Chronic Issues (if any)

Current Medications (if any)

Child #3 Information

CHILD #3 NAME

First Last

Gender

Male
Female

Date of Birth

Grade in School

Cubbies Vest Size

Please note sizes of Cubbies Vest Sizes in parentheses for most accurate fit.

Sparks Vest Size

Please note sizes of Sparks Vest Sizes in parentheses for most accurate fit.

T&T Shirt Size

Please note sizes of T&T Shirt Sizes in parentheses for most accurate fit.

Allergies & Medical/Chronic Issues (if any)

Current Medications (if any)

PARENT/LEGAL GUARDIAN

Name of Parent(s)/Legal Guardian:*

Address:*

Street Address Address Line 2 City State ZIP Code

Parent/Guardian's Phone #*

Email Address*

Emergency Contact #1 (other than Parent/Guardian)*

Emergency Contact #1 Phone #:*

Relationship to Child*

Emergency Contact #2 (other than Parent/Guardian)*

Emergency Contact #2 Phone #:*

Relationship to Child*

People Authorized to Pick-Up Your Child (if you cannot):*

Do NOT leave blank ~ write "NONE" if there is to be no one else.

I would like to request a Scholarship for my child(ren).

I would like to request a partial scholarship.
I would like to request a full scholarship.
I would like to offer to cover a child's cost if needed.

How much would you be willing to contribute toward your child's costs?

Please enter a number from 1 to 100.

I'd be interested in helping with Awana on Wednesday nights.*

Yes
No
Occasionally

Hidden

INSURANCE INFORMATION

Hidden

Insurance Company/Provider

Hidden

Subscriber Name (Main Policy Holder)

Hidden

Subscriber #

Hidden

Group #

Other Comments & Information

Medical and Release of Liability Form*

YES

I hereby authorize any of the Erieside Church children's & youth ministry leaders to consent to any medical treatment and hospital care which is deemed advisable and is to be rendered under the general or specific supervision of any licensed physician or surgeon. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power to the Erieside Church youth ministry leaders and volunteers to give specific consent for such diagnosis, treatment, or hospital care which the physician, in the exercise of his best judgment, may deem advisable.

Photography Consent*

YES

I grant Erieside Church and/or the Faith Friends/Youth Group Leaders permission to photograph the minor(s) designated above in any manner for any lawful purpose associated with the children's program at Erieside Church

Electronic Signature (type your full name in space below):*

I agree that my electronic signature is the legally binding equivalent to my handwritten signature, and has the same validity and meaning as my handwritten signature.

Awana Clubs (2022-23)

September 28, 2022 @ 6:30 pm - 8:00 pm

Awana Clubs Registration (2022-23)

Register up to 3 children

Child #2 Information

Child #3 Information

PARENT/LEGAL GUARDIAN

INSURANCE INFORMATION

Details

Organizer

Venue

Details

Organizer

Venue

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