2021-2022 Cubbies Club Registration

Rock Prairie Church, 421 Ash Street, Tipton, IN 46072
(765)675-4588
Awana is held Wednesdays from 6:00-7:30 p.m.
Please fill out this form and click submit.

Student Name

Birthdate

Entering Kindergarten Fall of

Address

Phone

Cell Phone

Parent/Guardian Name

This address will receive a confirmation email

Emergency Contact

Relationship

Emergency Contact Phone

Invited by

Church

Special Consideration(s)

Siblings also attending AWANA

I give my permission for the above student to participate in AWANA activities and games, and I realize that even when carefully supervised there is a chance that he/she could get hurt.

Please select all that apply.

By checking this box I give my permission for the above statement.

I will not hold the church and/or its representatives liable for injury, and I give my permission for the above named child to be treated in case of an emergency.

Please select all that apply.

By checking this box I give my permission for the above statement.

Yearly Club Dues

Yearly ($20.00) Pay in Person (0)

Amount

Cubbies Vest

Vest ($16.00 ) Already have one (0)

Amount

Vest Size

Please select one option.

Small (4) Medium (5) Large (6) X Larger (7) XX Large (10)

Handbook

Handbook ($16.00) Already have one (0)

Amount

Drawstring bag (Optional)

No Thank You (0) Bag ($8.00)

Amount

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

Rock Prairie Church, 421 Ash Street, Tipton, IN 46072
(765)675-4588
Awana is held Wednesdays from 6:00-7:30 p.m.
Please fill out this form and click submit.

2021-2022 Cubbies Club Registration

Description

Please Fix the Following