Awana Clubs Registration Form • Liberty Chapel Community Church

Liberty Chapel Community Church - Awana Clubs 2023-2024

Participants Information

First Name *

Last Name *

Gender *

Date of Birth *

Age *

School Grade *

Tip: Please enter participants grade for Fall 2022

Vest or T-Shirt Size

Parent/Guardian's Information

First Name *

Last Name *

Home Address *

Home City *

Email Address *

Mobile Number *

Would you like to add an additional parent/guardian? (By adding an additional parent/guardian you are authorizing them to check in and check out the registered participant.)

Yes

First Name *

Last Name *

Relationship to participant *

Home Address (If different than primary parent/guardian)

Cell Phone Number *

Email Address

Are you registered in our Check-In program? *

Yes

Would you like to add Additional Authorized Person(s)? They must be 18yrs or older. They will be able to check-in and check-out registered participant.

Yes

#1 Additional Authorized Person (Please enter the authorized persons name and phone number. Authorized person MUST be 18yrs. of age or older.)

#2 Additional Authorized Person - (Please enter the authorized persons name and phone number. Authorized person MUST be 18yrs. of age or older.)

#3 Additional Authorized Person - (Please enter the authorized persons name and phone number. Authorized person MUST be 18yrs. of age or older.)

Emergency Contact Information

Emergency Contact *

Emergency Contact Cell Phone Number *

Health & Medical Information

Allergies *

Yes

Please list all allergies. *

Chronic Illness

Yes

Tip: Information is voluntary

Please list any chronic illness

Special Needs Child

Other Conditions

Anything else we should know about the participant?

Additional Information

Photo ID: For the security of your child(ren), at the time of pick-up all authorized persons may be requested to show a government issued photo ID.