2013/14 AWANA Registration

First Presbyterian Church, Fresno

Please Circle Club Registering For:

Grades K-2nd

Ages 3-4

Grades 3rd-6th

Grades 7th-12th

Child's Name_______________________________________________________________________________
Date of Birth (mm/dd/yyyy) ______________________________ Gender

Male

Female

Parents/Guardian ___________________________________________________________________________
Street Address____________________________________________________________ Apt # ____________
City, State, Zip _____________________________________________________________________________
Home Phone (

)_______________________________ Cell Phone (

)_____________________

Parent's Email Address _______________________________________________________________________

Emergency Contact Person ___________________________________________________________________
Emergency Contact Telephone (

)_________________________/(

)_____________________

Please Check All That Apply: Asthma ________ Seizure Disorder _____________ ADD/ADHD ___________
Other Significant Condition ___________________________________________________________________
Allergies __________________________________________________________________________________
Physician ____________________________________________ Telephone (

)____________________

Health Insurance Co. ________________________________________________________________________

Brought To Club By ____________________________ Parent's Location During Club ___________________
Do you have a home church?

Yes

No

Home Church ________________________________

(If not, please consider making First Presbyterian your home church. We would be overjoyed to have you!)
--------------------Release permitting photo usage of minors-------------------I give Awana staff permission to use and publish any photos of my child taken during club time to be use for Awana
purposes only. (No names of participating children will ever be published.)
Signature of Parent ________________________________________________ Date _____________________________
--------------------Release permitting medical treatment for minors-------------------I understand that every effort will be made to contact me in case of illness, accident, or other emergencies requiring
medical treatment for my child. However, if it is impractical to do so, I hereby give my permission to the physician
selected by the church staff to secure treament, to hospitalize, to order anesthesia, x-ray, or surgery for my child.

Signature of Parent___________________________________________ Date __________________________

-----For Office Use Only----Registration Paid _________
Amount $__________
Cash____ Check_______ Check #_____

Registration Fee: $20 per year

(includes prizes, fees, & awards Due upon registration)
Uniforms: $16 S___ M___ L___ XL___ XXL___
Uniforms are one time purchase for first-year clubbers
Handbooks available upon completion of starter pamphlets