Please plan to attend our Registration Kick-Off night on Wednesday, Sept 13th at 6:30pm – EVEN if you register online! FieldsetChild's FULL Name *Example: Sarah FosterBirthdate *ex mm/dd/yyGrade *PreKkindergarten1st2nd3rd4th5th2nd Child's FULL Name Birthdate Grade prekKindergarten1st2nd3rd4th5th3rd Child's FULL Name Birthdate Grade prekkindergarten1st2nd3rd4th5th4th Child's FULL Name Birthdate Grade prekkindergarten1st2nd3rd4th5thParents Name(s) *Phone *Email *Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountryPlease tell us your home church *Choose all that apply *We are a returning familyWe have never participated in AWANA beforeWe have done AWANA, but not at this churchWe attend another church, but will attend this AWANA programWe do not have a church home, but will attend this AWANA programAWANA is a part of our homeschooling curriculumConsent of Treatment *I understand that in the event medical treatment is required, every effort will be made to contact me. However, if I cannot be reached, I do hereby authorize Avondale Bible Church as an agent for my child to consent to an x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician or surgeon licensed under the provisions of the PHYSICIANS AND SURGEONS ACT and on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. It’s understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority & power on the part of our aforesaid agent, to give specific consent to any and all such diagnosis, treatment or hospital care which aforesaid physician in the exercise of his best judgment may deem advisable. I further agree to indemnify and hold harmless Avondale Bible Church, their leaders, agents, sponsors, and any members from any liability or personal injury, loss, or damage that may be sought by any party for any reason whatsoever as a result of said minor(s) participation in the above named event.I agreeI DisagreeFamily Physican and Phone Number *Dr. Healthy 425-555-1212Family Dentist and Phone Number *Dr. Clean-teeth 425-555-1212Insurance Company & Policy Number *Blue Cross Policy Number 5551212Please list any medical allergies, food allergies, chronic illness or other conditions that we should be aware: *Photo release *I also hereby grant permission to Avondale Bible Church to use photographic images containing photograph/likeness of said minor for various purposes such as printed material, publications, displays, video productions, PowerPoint presentations, etc., as well as for the Avondale Bible Church website on the World Wide Web (WWW). I also acknowledge Avondale Bible Church's right to crop or treat the photographic image at its discretion.I AGREEI DISAGREEOther Contact in case of an Emergency *Emergency contact phone number * VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
