Registration 2016 – 2017 School Year

Register now for the Fall 2016 session. After filling out the form, payment can be made by bringing a check to the next club meeting or contact Matt Chambers at awana@nullleesvillebaptist.com for financial assistance availability. This form works best in Google Chrome (you may experience submission errors with date fields in other browsers).

Fall Session: September 14th – November 16th
Spring Session: February  – April (dates TBD)

Parent/Guardian Name(s):

Address:

City, State:

Zip Code:

Telephone:

Email:

Family Church:

School Child/Children attends:

Emergency Contact during Club Time (other than parent):
Name
Phone

First Child:
Name
Birth Date MM/DD/YYYY
Gender
Grade in September
AWANA Experience:

Second Child:
Name
Birth Date MM/DD/YYYY
Gender
Grade in September
AWANA Experience:

Third Child:
Name
Birth Date MM/DD/YYYY
Gender
Grade in September
AWANA Experience:

Fourth Child:
Name
Birth Date MM/DD/YYYY
Gender
Grade in September
AWANA Experience:


Terms and Conditions:

1) I understand that my child/children may participate in physical activities such as those held during game time. As with any physical activity, there is risk of injury. I fully accept this risk, and hold harmless from any legal liability, Leesville Baptist Church and any persons involved in the Awana Club ministry. Select:

2) In the event of an emergency that requires medical treatment for the above-named child/children, I understand every effort will be made to contact me or my emergency contact. However, if I/we cannot be reached, I give my permission to Awana volunteers to secure the services of a licensed medical professional to provide the care necessary for my child’s well being. I assume responsibility for all costs connected to any accident or treatment of my child. Select:

3) I grant permission for photos of my child to be taken for promotional purposes/slideshow for special occasions. Select:

4) I grant permission for my child’s club leader or program director to periodically contact me or my child by mail, email, or phone. If a home visit is desired, my permission will be requested beforehand. Select:

I have read and agree to the terms stated above.
Name
Date MM/DD/YYYY

I would like to learn more about the ministries of Leesville Baptist Church:

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