Register Below

 

 

 

 

 

 

 

All information will be kept confidential

First Name*

Last Name*

Address*

City*

State/Province*

Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip/Postal Code*

Email Address*

Phone*

Name of Child #1, Gender, Age, Grade, Date of Birth, and Known Allergies*

Name of child #2, Gender, Age, Grade, Date of Birth, and Known Allergies

Name of Child #3, Gender, Age, Grade, Date of Birth, and Known Allergies

Name of Child #4, Gender, Age, Grade, Date of Birth, and Known Allergies

Do you attend church? If so, where?*

Emergency Contact, Phone Number & Relationship to Child*

Emergency Contact, Phone Number & Relationship to Child*

Do you consent to and approve you child/children to take part in any and all activities conducted by Dalzell Baptist Church Awana Club?*

Do you give permission for photos of your child/children to appear among other general club photos in any and all media as long as there is no identifying information published by Dalzell Baptist Church?*

Your Name will serve as your signature*

Enter the code displayed*