Awana RegistrationIf you are human, leave this field blank.Today's DateStudent's Name*Parent/Guardian Name*Address*Email AddressDo you want to receive information via email? Yes NoHome Phone*Cell Phone Grade*Date of Birth*Age*Home churchYour child will not be released from Awana to anyone other than the parents/guardians listed above. If anyone other than the parents/guardians listed above will be picking up your child at the close of Awana (including parents of other children), you must tell us who you are authorizing to do so.Is there anyone who is NOT authorized to pick up this child? Yes NoWho may NOT pick up this child:In case of an emergency during Awana, please call Jennifer Troxell at 570-809-1201. if someone other than those listed above will be picking up your childI am the parent/guardian with legal custody of this childAs a parent/guardian, I authorize medical treatment, under the direction of any licensed physician in the event of a medical emergency. This authority is granted only after a reasonable effort has been made to contact me at the phone number listed in this form. I assume responsibility for any costs connected with treatment and release CCUMC and it’s Awana program from any liability. This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence.Emergency Contact Name*Phone*Emergency Contact Name*Phone*Allergies/Medical Information/OtherHealth Insurance Company and ID#Physician's NamePreferred HospitalI give consent for CCUMC’s Awana program to display my clubber’s photo in any form outside of the church including websites, newspapers and promotional materials, etc.As an Awana parent, I promise to help my Clubber to the best of my ability. I have shared the Awana rules with him/her and we have talked about what happens if he/she chooses not to obey the rules. I will be supportive by helping to memorize Bible verses, check their bag weekly and send their handbook and uniform weekly. I play a key role in helping my child learn and grow as a Christian.