Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Pomotional Media Disclosure *

Pictures/video of AWANA events are used to promote the ministry in bulletins/flyers and online. We do not use children's names in any promotional material - just pictures/video. By checking yes below you authorize this use. Please check the no box if you do not want your child(ren)'s picture presented in this manner. We are very discretionary in our publications but respect parental choice.

Yes

No

Date

MM

DD

YYYY