2018 / 2019 AWANA Registration

* Indicates required field

Clubber's Name *

First

Last

Grade as of Fall of 2018 *

Age (as of September 1, 2018) *

Birthdate *

Gender *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Mom's / Guardian's Name *

Mom's / Guardian's Cell Phone # *

Dad's / Guardian's Name *

Dad's / Guardian's Cell Phone # *

Land Line Phone Number *

E-Mail Addresses *

Primary Emergency Contact, if parent's cannot be reached *

Emergency Contact Phone Number *

Names of Siblings in AWANA *

Who can pick up? *

Who can NOT pick up? *

Home Church *

Allergies or Special Instructions *

Submit