2024-25 AWANA Bible Club

Registration Form

Starting again in September

Get an early start and register your child or children, today!

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- Step 1 of 3

Family Name *

Home Address *

Mom's Name *

Mom's Phone # *

Dad's Name *

Dad's Phone # *

Emergency contact if parent or guardian cannot be reached *

Emergency Contact Relationship to Child *

Emergency Contact Phone # *

Best phone # to receive occasional texts *

Best e-mail to receive club updates/announcements *

CLUBBER INFORMATION

(List names from youngest to oldest of all children living in the same household)

First Name *

Birthdate *

Grade *

Special needs, medical conditions, dietary needs or allergies *

List special needs for above named child

First Name

Birthdate

Grade

Special needs, medical conditions, dietary needs or allergies

List special needs for above named child

Name

Birthdate

Grade

Special needs, medical conditions, dietary needs or allergies

List special needs for above named child

Name

Birthdate

Grade

Special needs, medical conditions, dietary needs or allergies

Name

Birthdate

Grade

Special needs, medical conditions, dietary needs or allergies

List special needs for above named child

Photography Release *

Yes, I give my permission
No, I do not give my permission

Please check the box to give consent to use your child's image/photos for occasional use on the church ministry website.

I agree to the following charge (s): *

Registration Fee 1 child - $30.00
Registration Fee 2nd child - $20.00
Registration Fee 3rd child - $10.00
Registration fee - family of 4 or more $60 limit - $60.00
Registration fee 7-12 grade - $10.00

If you are experiencing financial difficulty - please still register and see the Director on the first night of club for a financial scholarship form. The church will be glad to help you with the cost.

Number of children attending

Total *

$0.00

PAYMENT INSTRUCTIONS:
Make a check payable to CEFC and mail to address below. Please write AWANA Registration in the check memo.

2420 Blakeslee Blvd. Dr. West, Lehighton, PA 18235

You can also bring your payment to the first meeting.

CEFC LIABILITY RELEASE

In consideration of Christ Evangelical Free Church (herein referred to as CEFC) allowing the Participant in CEFC AWANA Ministries, we (I), the undersigned, do hereby release, forever discharge and agree to hold harmless CEFC, its employees, and its volunteers from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage expenses of any nature whatsoever which may be incurred by the undersigned and the Participant, hereby grant our (my) permission for the Participant to participate fully in CEFC events.

Furthermore, we (I) [and on behalf or our (my) minor Participant] hereby assume all risk of accidental personal injury, sickness, death, damage, and expense as a result of participation in all activities involved therein. The undersigned agrees to hold harmless and indemnify CEFC for any liability sustained by CEFC as a result of negligent, willful or intentional acts of Participant, including expenses incurred attendant thereto.

MEDICAL TREATMENT PERMISSION

We (I) authorize an adult in whose care the minor Participant has been entrusted, to consent to any emergency x-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care to be rendered to the minor Participant under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility.

The undersigned shall be liable and agree(s) to pay all cost and expenses incurred in connection with such medical and dental services rendered to the aforementioned minor Participant pursuant to the authorization. Every effort will be made to call the parent / guardian first before resorting to assuming medical treatment, unless there is a life-threatening emergency.

Are children covered by Medical Insurance? *

Who is the Insurance Company?

Policy Group ID#

PARENT/GUARDIAN AUTHORIZATION

Please check the box on the left and insert your full name and the date you are submitting this form.

Please Note:

Checking the box and adding my name below to this consent/liability release/medical permission form it is an acknowledgement that I have read and understand these guidelines. I recognize that this is a medical release, and liability release for the entire 2024-2025 AWANA Club year.

PARENT/GUARDIAN AUTHORIZATION

Authorization *

I accept & acknowledge these guidelines

Name *

Date *

Authorization *

I accept & acknowledge these guidelines

Name *

Date *