2010-2011 Registration

Child 1 Last Name :

Child 1 First Name :

Child 1 Date of Birth :

Child 1 Current Grade :

Child 2 Last Name :

Child 2 First Name :

Child 2 Date of Birth :

Child 2 Current Grade :

Child 3 Last Name :

Child 3 First Name :

Child 3 Date of Birth :

Child 3 Current Grade :

Child 4 Last Name :

Child 4 First Name :

Child 4 Date of Birth :

Child 4 Current Grade :

Child 5 Last Name :

Child 5 First Name :

Child 5 Date of Birth :

Child 5 Current Grade :

Father's Full Name :

Mother's Full Name :

Home Phone Number :

Cell Phone :

Alternate Phone Number :

Email Address :

Address :

City, State Zip :

Emergency Contact :

Phone Number :

Emergency Contact :

Phone Number :

Emergency Contact :

Phone Number :

Medical Care Provider :

Medical Contact Number :

Medical Issues/Restrictions/Allergies :

AWANA Class Level :

Cubbies (3-5 yrs; Pre-K)
Sparks (5-8 yrs; Grade K-2)
T & T (8-11 yrs; Grade 3-6)
Trek (11-13 yrs; Grade 7-8)
Journey (13-18 yrs; Grade 9-12)

Names of persons authorized to pick up your child :

Do you regularly attend ASC?

Yes No

If no, what church do you attend?

Prices :

Regular ASC Attenders

1 child : $35.00

2 children : $65.00

3 children : $90.00

4+ children : $110.00

Non-Regular ASC Attenders :

1 child : $50.00

2 children : $80.00

3 children : $110.00

4+ children : $130.00

Products :

Cubbies Uniform ($12)	Cubbies Book ($10)
Sparks Vest ($14)	Sparks Book ($10)
T & T Vest ($16)	T & T Book ($10)
No Trek Vest	Trek Book ($10)
No Journey Vest	Journey Book ($10)

Disclaimer :

To Whom It May Concern: As a parent and/or guardian, I do herewith authorize treatment under the direction of any licensed physician and the afore mentioned minor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment, or in extreme discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me by phone at the numbers provided. By clicking the box below, the undersigned assumes the responsibility for any costs connected with such treatment and hereby releases AWANA Clubs International, Antelope Springs Church of Roseville, CA, the vehicle driver of any vehicle driven if transport is part of the event, from any liability therefore.

I agree to the above terms and conditions.