Preston Oaks Baptist Church
AWANA
Awana Page 1
page 1 of 1
Name of Child
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First Name
Last Name
Age of Child & Last School Grade Completed
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Gender of Child
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Female
Male
Address
Address
Address Line 2
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Guam
Marshall Islands
Micronesia
Northern Marianas
Palau
Puerto Rico
Trust Territories
Virgin Islands
Armed Forces(AA)
Armed Forces(AE)
Armed Forces(AP)
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territory
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
City
State
Zip Code
Name of Parent or Guardian
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First Name
Last Name
Phone Primary Contact Information for Parent/Guardian
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Phone Number
Secondary Contact Information for Parent/Guardian
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Phone Number
Email
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Email Address
Allergies: Please describe any food allergies or environmental allergies and describe possible reactions that may occur:.
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Please list those who are AUTHORIZED to pick up your child from Awana.
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Emergency Contact Name (other than parent)
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First Name
Last Name
Emergency Contact (other than parent)
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Phone Number
I, the undersigned, request that my child (ren) be permitted to participate in the Preston Oaks Baptist Church Awana Ministry. I agree to hold harmless Preston Oaks Baptist Church or any of their agents in the event of accident, illness, injury, or death, which may occur during any and all Awana Sponsored activities. I hereby consent to my child’s participation in interviews, the use of quotes and the taking of photographs, movies or video tapes while participating in a Preston Oaks Baptist Church activity or function. I also grant permission to Preston Oaks Baptist Church to use my child’s name and/or photographs for use in brochures, newsletters, and webpage as well as other forms of media not mentioned. I also hereby release Preston Oaks Baptist Church from all claims, demands, and liabilities whatsoever in connection with the above.
Agreement and endorsement of above paragraph
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NO
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