Awana Children's Form

Child's Name (required)

Date of Birth (required)

Age (required)

School (required)

Grade 2015/2016 School Year (required)

Medical Information / Special Needs

Parent's / Guardian's Name (required)

Address (required)

City (required)

State (required)

Zip Code (required)

Phone Number (required)

Cell Phone (required)

Your Email Address (required)

Do you attend church? If so, where?

Emergency Contact Name

Emergency Contact Number


Please check off the club that corresponds with your child's
grade in school this year:


*In the event of an emergency, we will attempt to contact you and will initiate
emergency care for your child, if needed.

*Your child may be photographed or videotaped during normal ministry activities,
and these photos and / or videos may be used in promotional materials.