AWANA Registration Form Please enable JavaScript in your browser to complete this form.Child Name *FirstLastAge Selected Value: 3 Date of Birth *mm-dd-yyyyLast Grade Completed *3yrs4yrsPre-KK1st2nd3rd4th5thAddress *City *State *ZIP Code *Parent/Guardian *FirstLastPrimary Phone *Alternate Phone EmailEmailConfirm EmailDo you have a Church home?YesNoIf Yes, Where?Emergency Contact *FirstLastEmergency Contact Number *Medical Allergies *Enter None if not applicableI authorize the following people (in additions to the parents listed above) to pick up my child from any AWANA sponsored gatherings.FirstLastFirstLastFirstLastI give permission for photos or videos of AWANA activities which may contain my child to be used on Heber Springs Baptist Church media platforms. *YesNoQuestions? If you have any questions about our AWANA program, please let us know.Being the legal guardian of the minor named herein, by check box and signature I give Heber Springs Baptist Church and/or its sponsors the authority to secure any medical and/or surgical treatment for the child names above that is determine necessary in the event of an emergency, sickness, or accident. *I Agree to the statement aboveSignature *FirstLastThis signature authorizes that I am legal guardian of the minor names herein.Submit