Sign-up sheet for the 2009-2010 AWANA program.

By submitting this form you are acknowledging that all information is correct to the best of your knowledge. Also, by submitting this form, you hereby give your consent for emergency medical treatment to be provided to the child listed on this webform in the event that all efforts to contact you prove to be unsuccessful.

Please, view the attached packet of information (club rules, dues, director contact number's, etc.) at the bottom of this webform. If you have any questions, please, contact the church office at 501-778-4103.

First Name: *

Last Name: *

Date of Birth: * mm/dd/yyyy

Grade:

Sex: * Male/Female

Allergies/Special Needs:

Club:

Puggles (2 yrs.), Cubbies (3 yrs. [before Sept. 1, 2009]-4 yrs.), Sparks (K-2nd), Truth and Training (3-5 grade), Trek (6-7 grade)

Parent(s) Name: *

Address: *

City: *

State: *

Zip Code: *

Home Phone: xxx-xxx-xxxx

Cell Phone: * xxx-xxx-xxxx

E-mail:

Emergency Contact Number: * xxx-xxx-xxxx

Secondary Pick-up: * Name/Relationship

Someone you would authorize Sharon Baptist Church to release your child to. (in the event Parent's can't pick-up)

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