AWANA Registration

*Required field

Child's Information
Name
Address
City
State
Zip
Age
Date of birth
Grade (for fall 2011)
Sex	Male Female
Parent/Guardian Information
Name
Phone
Cell
Email*
Does your child have any medical conditions(s) that we should be aware of, such as, allergies, medications, etc?  If so, please explain.
Please complete this form with your signature by typing your complete name and date in the fields below.
Name
Date
If you have any questions please contact Dean Smith at 304-829-4700.