AWANA 2010/2011 Registration Form

1 Parent/Guardian First Name Last Name

2 Parent/Guardian First Name Last Name

Address

City Zip

Evening #

Emergency # or Cell #

Primary Family Contact Email

Does your child/children need bus pickup? If so, please contact Susie Sherrill in the church office to let her know. 704-483-5851

Clubber 1 : Your Child's Name

Birthdate: Month, Day and Year

Male

Female

If in School - Grade

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Clubber 2 : Your Child's Name

Birthdate: Month, Day and Year

Male

Female

If in School - Grade

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Clubber 3 : Your Child's Name

Birthdate: Month, Day and Year

Male

Female

If in School - Grade

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Clubber 4 : Your Child's Name

Birthdate: Month, Day and Year

Male

Female

If in School - Grade

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, Westport Baptist Church and any persons involved in the AWANA Club Ministry.

2) In the event of an emergency that requires medical treatment for the above named child/children, I understand that every effort will be made to contact me. However, if we cannot be reached, I give my permission to the AWANA volunteers to secure the services of a licensed physcian to provide the care necessary for my child's well being. I assume responsibility for all cost connected to an accident or treatment of my child/children.

3) I grant permission for a photo of my child to appear in an unpublished club directory to be used by AWANA Leaders only.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 is no identifying information, to include the Westport Baptist Church web site at http://www.westportbaptist.net.

Are there any allergies or special needs we need to know about your child/children?

Parent/Guardian Signature_______________________________ Date____________________

(If you email this Registration Form by hitting the Submit Button below, this is your consent to the above Terms and Conditions)