Parent / Guardian Name *

First Name

Last Name

Student name *

First Name

Last Name

Parent / Guardian Cell Phone *

(###)

###

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Parent / Guardian Home Phone

(###)

###

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student DOB

MM

DD

YYYY

Emergency Contact 1 *

First Name

Last Name

Emergency Contact 1 # *

(###)

###

####

Emergency Contact 2

First Name

Last Name

Emergency Contact 2 #

(###)

###

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AWANA Club *

What Group Will Your Child Be Attending

Puggles (Ages 2-3)

Cubbies (Ages 3-5)

Sparks (Kindergarten-2nd Grade)

T&T (3rd-6th Grade)