Mt. Zion UMC Awana Registration Child Name * Date of Birth * Age * Year in School * Preschool Kindergarten 1st 2nd 3rd 4th 5th 6th Street Address * City * State * AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code * Contact Number * Email Address (if available) Mother's Name Type Home Work Cell Contact Number Father's Name Type Home Work Cell Contact Number Name of Family Doctor Contact Number Emergency Contact * Emergency Contact Number * Is your family currently attending a church? * Yes No If so, what church are you attending? Does your child have any limiting health conditions? * Yes No List all conditions: * Does your child have any allergies? * Yes No List all allergies: * Are there any other special instructions for your child's care? * Yes No List other instructions: * I give permission to the following individuals to pick up or drop off my child or ward at Awana: Permission to Pick Up * Enter "N/A" if no other individuals have permission to drop off or pick up your child. I give permission for this child to be photographed at Awana by news media that could possibly publish their name and image. * Media Release * Yes No I give permission for this child to have his or her picture used to show Awana activities on the Mt. Zion United Methodist Church website without using first or last name. * Website/Social Media Release * Yes No Name of Person Submitting * reCAPTCHA If you are human, leave this field blank.