Awana

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birthday

School Grade

Phone Number

Area CodePhone Number

E-mail

Parents Names

Church

Brought By

By checking box below I hereby authorize medical care or first-aid treatment for my child listed above in the event of illness or injury during any sponsored activity of White Lake Baptist Church. This permit is in effect until I give White Lake Baptist Church written notice to the contrary.

Parent/Guardian giving permission

Health Insurance Company

Subscriber's Name

Policy Number

Insurance Company's emergency phone number

Emergency Contact Information, Please provide name, address, phone number and relation to child.(please give three options)

Has he/she had any surgery or serious illness within the last three years

If yes please explain:

Is he/she required to take any medication

If yes, for what reason and how often

Does he/she have any allergies or allergic reaction to any medication

If yes please explain:

Is he/she presently under a doctor's care

If yes please explain:

Date of last Tetanus injection

AWANA Registration Form