Awana Registration
Please complete the form below and select the submit button to process.
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Indicates Required Fields
Name Of Clubber:
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Address:
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City:
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Zip:
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Phone:
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Age:
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Date of Birth:
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Please Enter Your Email Address Below:
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For Security Purposes Please Re-Enter Your Email Address Below:
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Emergency Contact Person:
Parent/Guardian:
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Address:
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Phone:
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Cell:
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Alternate Contact Person:
Name:
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Address:
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Phone:
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Cell:
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Relationship to clubber:
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Insurance Information:
If you have insurance, your carrier will be billed for medical charges in the case of illness or injury.
Do you have health insurance?
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Yes:
No:
Insurance Company:
Policy #:
Family Doctor:
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Phone:
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Health History:
(use the text fields below each category to provide detailed information)
Allergies:
Current Medications:
Pre-existing Medical Conditions
Medical and Liability Release Statement:
I understand that if medical intervention is needed, every attempt will be made to immediately contact the persons listed on this
form. If I cannot be reach in an emergency, I hereby give my permission to secure medical treatment for my child as deemed
necessary.
I understand the Martensdale Community Church Awana Clubs will take all reasonable safety precautions and I understand the possibility of unforeseen hazards and know the inherent possibility of risk.
I agree not to hold Martensdale Community Church, its Awana leaders or volunteers liable for damages, losses or injuries incurred by the subject of this form.
By placing your name in the E-Signature box below you agree to the terms of this document. The E-Signature Act became law in 2000. Under this law, online "electronic" signatures have the same legal status as a written signature.
Parent/Guardian E-Signature:
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Date:
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FOR OFFICE USE ONLY:
Registration Fee:
Yes:
No:
© 2007 Martensdale Community Church - An Evangelical Free Church
Box 200 | Martensdale, IA 50160 | PH: 641.764.2491 | FX: 641.764.2443
