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Awana Enrollment Form

AWANA ENROLLMENT FORM

Please fill out one per child.

First Name:
Gender:
Address:
Home Phone:
Birthdate:
Age:
Grade:

Parent/Guardian Information

Child lives with:
Father’s Full Name:
Work Number:
Cell Number:
Email:
Mother’s Full Name:
Work Number:
Cell Number:
Email:

Emergency Contact Information

Name:
Relationship:
Work Number:
Cell Number:
Email:
Any Special Concerns:
Pick up by:

Liability Release and Emergency Medical Treatment Agreement

Medial Release On Behalf Of Minor And Hold Harmless Agreement

My son/daughter has my permission to attend Awana 2017-2018 at Christ the Healer Church.

I UNDERSTAND AND DO HEREBY AGREE TO ASSUME ALL OF THE RISKS AND OTHER RELATED RISKS WHICH MAY BE ENCOUNTERED BY MY SON/DAUGHTER PARTICPATING IN AWANA.

The undersigned hereby release and forever discharges Christ The Healer Church, its staff, adult leaders, and any other persons, who it might be claimed to be liable. None of whom admit any liability from any and all claims, demands, actions, causes of ac on or suits of any kind or nature whatsoever and particularly on account of all injuries known and unknown, both to person and property, which have resulted or may in the future develop from any accident which might occur as a result of joining AWANA sponsored by Christ The Healer Church.

I further state that I HAVE CAREFULLY READ THE FORGOING RELEASE AND KNOWN THE CONTENTS THEREOF AND IS SIGNING THIS RELEASE AS AN ACT OF MY OWN FREE WILL. This is a legally binding agreement which I have read and understand.

Physician Name:
Phone:
Medical Coverage :
Policy #:

Medical Release

I, the undersigned, do hereby grant or deny permission to Christ The Healer Church to use the image of my child, as marked by my selection(s) below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials, videos, and digital images.

Deny Permission

Grant Permission

CTH Awana Club registration fee is required to help us cover the cost of materials and handbooks used in AWANA. The fee does cover uniforms. That being said, we do not want any child to forego AWANA because of a lack of resources. Therefore, if the club dues are burdensome, please contact Pastor Lynnita Lockett. We will make some sort of arrangement with you.

Any donation to AWANA will be gladly accepted beyond your normal dues. Please indicate your desire below regarding Club registration.

Check all that apply and fill in the appropriate information below.

To be filled out by the church office.
Registration	Amount Due	Amount Page	Date Paid
$30/$50

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Your legal name

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Timestamp

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August 24, 2017 10:08 pm EDT

Awana Enrollment Form Uploaded by Michael Smith - msmith@ctsgraphics.net IP 68.55.27.178