Wiley Union Church / Children's Program / Awana Registration

Register for our event by filling out the information below:

Clubber's First Name

Clubber's Last Name

Gender

Male

Female

Clubber's Mailing Address

City

State

Zip Code

Clubber's Grade

Clubber's Age

Clubber's Birthdate (MM/DD/YEAR)

For which program are you registering your clubber?

Clubber's School

Clubber's Home Church (if applicable)

Are there any health/medical problems, allergies, or other restrictions in the clubber's participation? (If no, you can leave it blank)

Parent's First Name

Parent's Last Name

Parent's contact info:

Home Phone Number

Cell Phone Number

Email Address

What is the best way to reach you?

Home Phone

Cell Phone

Email

Would you like text messages for Club cancellations and updates?

Yes, please!

No, thanks!

Emercency Contact Information

Full Name of Emergency Contact

Emergency Contact's Cell Phone Number

Emergency Contact's Relationship to Clubber

Is there anyone who is restricted from having contact with the clubber or is restricted from picking the clubber up at the end of the night? If yes, please type their full name below.

I hereby give my permission for my child (named above) to attend and participate in "Wiley Union Church" AWANA Club and any special activities and events planned by the AWANA Club.

I do hereiwth authorize emergency treatment be given if necessary only after a reasonable effort has been made to reach us/me the parent(s) or guardian.

I the undersigned do hereby release and agree to hold harmless the AWANA Leadership, "Wiley Union Church", and AWANA Clubs International from any and all liabilities or claims for personal injury or illness which may be incurred by my child while attending and participating in the AWANA Club and its activities and special events.

I understand and hereby grant "Wiley Union Church" AWANA Club, its staff and leaders permission, that, while my child is participating in apporved AWANA Activities, photographs and videos of my child may be taken for use in promoting AWANA and its activities within "Wiley Union Church" and wileyunionchurch.com. I further release "Wiley Union Church" and its staff and leadership from any and all claims that I may have against them as a result of my child's picture being used in promoting AWANA within "Wiley Union Church" and wileyunionchurch.com I further understand that I may "Opt out" by selecting the appropriate "No, do not photograph or video my child" option immediately below.

If you would like to opt your child out of promotional photo and video use please select the option below

No, do not photograph or video my child for promotional purposes within "Wiley Union Church" and wileyunionchurch.com

Is there any additiona information we might need in order to effectively minister to the clubber? If no, please leave blank.

By clicking the "Register" button immediately below this text, I am digitally signing my consent to the above information for the 2018-2019 AWANA Club year at Wiley Union Church.

AWANA 2018-19 Clubber Registration Form