Awana Registration Name First Last NicknameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Birthday AgeGradeParent(s) Names First Last PhoneEmail Church you attendAre there any special needs or allergies we should be aware of?Whom it may concern: As a parent and/or guardian, I do herewith authorize treatment under the direction of a licensed physician of the above minor in the event of a medical emergency which in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me by phone at the phone number listed below. The undersigned assumes the responsibility for any cost connected with such treatment and hereby releases Bethel Baptist Church Awana Club from any liability therefore. The 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.Signed First Last Please indicate your roleFatherMotherGuardianFamily PhysicianPhoneHealth Insurance NamePhoneSpecific medical allergies, chronic illnesses, or other conditions:Emergency ContactPhoneAuthorized pickup (Must be 13 years or older)Please indicate who is authorized to pick up your child from Awana. We will not release them to anyone not previously approved by you.Unautorized to Pick upPlease indicate of there is anyone whom you do not want your child/children released to.Are there any Family Court Orders in place with your family?* Yes No Not Applicable Please explain your family court order: Please read: The Security team here at Bethel is working hard to ensure the security of the children attending Bethel's Children's programs. The following is information we would like all of our parents to be aware of. Children need to be signed in and out by a Parent or a person otherwise designated in your profile. We will add into your profile names of those who may or may not pick up your child/children. When signing in your child/children a name tag may be issued for the child/children as well as an ID tag for you as parent(s). This tag will need to be used in order to pick up your child/children. If this ID tag is lost or another individual you have designated in your profile picks up a child/children, a photo ID will be required. If you child/children brings a guest they will be signed in under your name and the above rules will apply. There will be no exceptions to the above information. Thank you, for entrusting your child/children into our care. We hope these changes will be a further step in caring for your children here at Bethel. By clicking submit you have read the above information and are in agreement. Should you have any additional questions, please contact us to discuss them.