Awana Registration 2008/2009

Salem Baptist Church
24032 Sparta Road
Sparta, VA  22552
(804) 633-5583

My child will be participating in the following club:   Cubbies      Sparks      T&T
                                    (Circle one)
Child’s Name         _____________________________

Address        _____________________________

            _____________________________

Phone            _____________________________

Age    ______    Date of Birth __________________        Grade _______

Parent/Guardian    _____________________________        

Address        _____________________________        E-mail (optional)        
        
            _____________________________        ______________________

Phone            _____________________________        

Cell Phone #        _____________________________        Authorized Pickup Person(s)

Home Church        _____________________________        _______________________

Emergency Contact    _____________________________        _______________________

Emergency Phone    _____________________________        _______________________



Your signature confirms that you have read and understand the rules set forth in the attached letter; that all of the above information is current, and that you are authorizing your child to participate in the 2008-2009 Awana programs at Salem Baptist Church.  
                                
                                
                            _______________________________________
                            Parent/Guardian Signature            Date



**Please complete and return this form to the club secretary**