AWANA Registration Form
2018/2019 Crossroads Chapel AWANA  - Registration/Medical Release Form
PARENT NAME(S)
PHONE - HOME and/or CELL
EMAIL
ADDRESS
CITY & ZIP
CHURCH AFFILIATION
Emergency Contact - if someone other than Parent
Medical Insurance Company
Home/Cell Number
Relationship to child
Policy or Group Number
(1) Child's Name
(1) Birthdate and School Grade
(2) Child's Name
(2) Birthdate and School Grade
(3) Child's Name
(3) Birthdate and School Grade
(1) Allergies/Other information
(2) Allergies/Other information
(3) Allergies/Other information
Parent/Legal Guardian Release Signature
Date
Release Statement
Submit
Parent/Legal Guardian Information
Child(ren) Information
Emergency Contact
Medical Information
Release
I do hereby give my permission for my child(ren) named above to attend and participate in all activities conducted by the AWANA program at Crossroads Chapel. 
I further give my permission for any adult volunteer to obtain necessary medical attention in case of sickness or injury to my child.   I have identified any medical conditions that might require special attention in the above form.

I do hereby release and discharge all adult volunteers and Crossroads Chapel from any and all claims, demands, actions or cause of action, present or future arising out of any damage or injury while my child is in their care while attending AWANA and associate AWANA events.

I, the undersigned, do hereby verify that all the information given on this form to be correct.
HOURS OF OPERATION
Monday - Saturday 9:30am - 8:00pm Sunday
10:00am - 7:00pm
4917 Rustic Prairie Passage
Loco Hills, Kansas
          
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