2009-2010 Goldsboro Wesleyan
Awana Registration Form
(Please do one form for each child you are
registering)
Father or Guardian:
Mother or Guardian:
Street Address:
City:
Goldsboro
Seven Springs
Mount Olive
Pikeville
Dudley
Eureka
Fremont
State:
North Carolina
Zip Code:
27530
27534
27531
27532
27533
28365
27863
28578
28333
27830
Home phone number:
Cell or pager number:
Your email address:
(for information and
emergency closings)
Goldsboro Wesleyan Church Release for Use
of Personal Images (Pictures/Videos)
From time to time during the club year, videos, photographs, and /or slides will
be taken of our Clubbers. These will be used for publicity purposes only.
I
grant
permission for Goldsboro Wesleyan Church to use videos,
photographs, and/or slides of my child for publicity purposes and /or
publishing to our website.
Please complete electronic signature
below and check box to confirm
I
do not
allow Goldsboro Wesleyan Church permission to use
videos, photographs, and/or slides of my child for publicity purposes
and /or publishing to our website.
Parent Electronic Signature:
regarding picture release
Child's Name:
Child's Date of Birth:
Male
Female
Name of School or
Home School:
List any food allergies,
health, or behavioral
concerns
Does child have a special
need or disability?
Is child in a specialized
classroom in school or
receiving special services in
class?
Custody concerns?
Please notify class
leaders regularly
No
Yes
I give consent for a responsible adult at the Awana ministry at Goldsboro Wesleyan Church to administer appropriate first aid to my child when needed. I also give consent to secure additional emergency treatment for my child, under the following conditions: reasonable effort had been made to find me at the Church or at home: the consensus of several adults is that care is needed prior to the probable return of the parent/guardian to pick up the child. I understand it is my responsibility to notify the classroom leaders as to where I can be reached in the event of an emergency. I do hereby state that I am the (a) parent and/or legal guardian of the child named below.
Child's Name
Child's Age
4
5
6
7
8
9
10
11
12
13
14
Electronic signature:
Date:
Goldsboro Wesleyan Church
