Awana Registration

Child's Information

Child's Name*

First Last

Address*

Street Address City State ZIP Code

Phone*

Birthdate*

Note: Child must be 3 years old by September 11, 2019 AND potty trained to begin Cubbies

Age*

Grade*

Gender*

Boy
Girl

School

Church Affiliation

Brought By

First Last

Parent's Information

Parent's Name (Primary)*

First Last

Parent's Name (Secondary)

First Last

Email*

Enter Email Confirm Email

Parent's Address (If different than Child's Address)

Street Address City State ZIP Code

Parent Daytime Phone*

Parent Evening Phone*

Parent Cell Phone

May we contact you via SMS Messaging (Text Message)?*

Note: Standard text messaging rates apply

Yes
No

Medical Information

Please Note: If you child needs to bring medication on campus or is required to take medication during AWANA program time, special arrangements will need to be made in writing with Tom Gerl, AWANA Commander.

Allergies / Disabilities / Current Medications

Health Insurance Provider*

ID / Policy #*

Phone Number of Medical Center or Physician*

Physician's Name

Is your child allergic to:*

My child has no known allergies.
Bee Stings
Pollens
Hay, Straw
Penicillin
Other Drugs
Other

My child is allergic to:*

Does your child have any life-threatening allergies?*

Yes
No

My child has life threatening allergies to:*

Does your child have any physical, emotional, mental, or behavioral concerns or limitations that our staff should be aware of?*

Yes
No

Please explain any physical, emotional, mental, or behavioral concerns or limitations our staff should be aware of:*

Has your child ever had:*

My child has none of the following conditions
Seizures
Asthma
Diabetes
Heart Disease
Other

My child has the following condition:*

Emergency Contact Information (Other Than Parent)

Name*

First Last

Phone Number*

Relationship*

Medical Release, Waiver of Liability, & Indemnity Agreement

Only the child's parent or legal guardian may sign this release. Your signature is represented by checked boxes. Please read the following statement(s) carefully and check the boxes below. All minors are required to have a parent or guardian's signature to attend The Long Beach Alliance AWANA Program. By checking the boxes on this electronic form you are agreeing to these written terms and conditions.

I(we) the undersigned, acknowledge participation in, and/or give permission for, my(our) minor child to participate in AWANA provided by Long Beach Alliance Church September, 2019 - May, 2020. I(we) the undersigned confirm I(we) am(are) legally 18 years or older and sign on behalf of myself(ourselves) and on behalf of my(our) child.*

Yes, I confirm and agree with these terms, and am signing this acknowledgement voluntarily.

I(we) am(are) the parent(s) or legal guardian(s) of the minor listed above and grant my(our) permission for him/her to fully participate in Long Beach Alliance Church AWANA events and activities. These activities include, but are not limited to, competitive and strenuous group games; inflatable toys; swings and playground styled equipment; water balloon games; squirt gun and water spraying activities; food games; games played by crawling on floor; games played with balls, rackets, etc.; throwing or flying projectiles; and/or running. I(we) understand that my(our) child may be photographed or videotaped during activities and that these photos/videos may be used in promotional materials published by Long Beach Alliance Church.*

Yes, I confirm and agree with these terms, and am signing this acknowledgement voluntarily.

I(we) understand the Long Beach Alliance Church staff, volunteers, and AWANA leaders will make every attempt to contact me as soon as possible in the event an emergency arises. If contact cannot be made, I(we) authorize the Long Beach Alliance Church staff, volunteers, and AWANA leaders to provide medical care, and if necessary, take my child to a doctor or medical facility. I(we) also authorize medical treatment recommended by medical staff and I(we) assume responsibility for all medical costs.*

Yes, I confirm and agree with these terms, and am signing this acknowledgement voluntarily.

I(we), on behalf of my(our) child, myself, my children, my assigns, and my estate, assume the risk and promise to release from liability and hold harmless for personal injury or sickness and/or damage to personal or public property resulting from my(our) child’s participation, Long Beach Alliance Church, its officers, Governing Board, Elders, agents, employees, and/or volunteers for any and all claims for injuries, causes of action, or liability related to my and/or my minor child’s participation in any Long Beach Alliance Church AWANA onsite or offsite activity. This release does not apply to intentional and/or willful acts of misconduct, willful negligence, or lack of supervision by trained adult volunteer staff by Long Beach Alliance Church or any of its officers, Governing Board, Elders, agents, employees, and/or volunteers. I(we) agree to indemnify and hold harmless the Long Beach Alliance Church, its officers, Governing Board, Elders, agents, employees, and/or volunteers for any liability incurred or property damage/loss sustained by Long Beach Alliance Church as the result of the negligent, willful, or intentional conduct of my child, including expenses attendant thereto.*

Yes, I confirm and agree with these terms, and am signing this acknowledgement voluntarily.

Cubbies Fees & Payments for Registration

Is this your first time attending Cubbies?*

Yes
No

Cubbies Annual Dues*

Price: $25.00

Cubbie Introduction Pack*

Includes Workbook, Uniform Vest, & Book Bag

Price: $33.00

Cubbie Workbook*

Note: A new Cubbie Workbook is required each year

Price: $12.00

Cubbie Required Products

Note: Each of these products is required for Cubbies. Please indicate which (if any) replacement products you need to order.

Book Bag
Cubbie Uniform Vest

Sparks Fees & Payments for Registration

Is this your first time attending Sparks?*

Yes
No

Sparks Annual Dues*

Price: $25.00

Sparks Products

Note: Each of these products is required for Sparks. Please indicate which (if any) replacement products you need to order.

Workbook
Sparky Uniform Vest

Sparks Introduction Pack*

Includes Workbook & Uniform Vest

Price: $27.00

Optional Sparks Book Bag

Price: $7.00 Quantity:

T&T Fees & Payments for Registration

Is this your first time attending T&T?*

Yes
No

T&T Annual Dues*

Price: $25.00

T&T New Workbook*

Note: A new Workbook is required for T&T (even if you didn't finish last year's book).

Price: $12.00

T&T Products

Note: Each of these products is required for T&T. Please indicate which (if any) replacement products you need to order.

T&T Uniform

T&T New Uniform*

Price: $20.00

Optional T&T Book Bag

Price: $10.00 Quantity:

Trek Fees & Payments for Registration

Is this your first time attending Trek?*

Yes
No

Trek Annual Dues*

Price: $25.00

Trek Introduction Pack*

Includes Workbook & Uniform

Price: $28.00

Trek Workbook*

Note: A new Trek workbook is required each year

Price: $11.00

Trek Uniform

Note: The uniform is required for Trek. Please indicate if you need to order a replacement uniform.

Trek Uniform

Journey Fees & Payments for Registration

Is this your first time attending Journey?*

Yes
No

Journey Annual Dues*

Price: $25.00

Journey Introduction Pack*

Includes Workbook & Uniform

Price: $37.00

Journey Workbook*

Note: A new Journey workbook is required each year

Price: $20.00

Journey Uniform

Note: The uniform is required for Journey. Please indicate if you need to order a replacement uniform.

Journey Uniform

Total Fees

Total

$0.00

To Complete Registration

TO COMPLETE REGISTRATION PRESS BLUE "SUBMIT REGISTRATION" BUTTON BELOW

To pay via Check or Cash: Press "Submit Registration" button below. You will be redirected to a PayPal page. You do NOT need to enter in PayPal information and may close your browser window. Checks may be made to "LBAC" and may be dropped off in the church office or on Opening Night, Wednesday, September 11.

To pay via PayPal, Debit, or Credit Card: Press "Submit Registration" button below. You will be redirected to a PayPal page. You may sign into your PayPal account to complete your payment or you may choose "Pay with PayPal Credit, Debit, or Credit Card" to complete your registration as a guest without a PayPal Account.

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