colonial hills church
 

I am registering for:
First Name
Last Name
Preferred Name
Address
City, State, Zip
Home Phone
Cell Phone
Work Phone
Parent/Guardian Name
Contact Email
Child's Grade
Child's Birthday
Child's Gender
Child's Age
Name of Adult Bringing Child to AWANA
Adult's location during AWANA (in case of emergency, we must have a responsible adult on one of the CHC campuses)
In case of an emergency, a representative of Colonial Hills Church is authorized to take such measures and arrange for such medical and hospital treatment as they may deem advisable for the health and well-being for my child. I release Colonial Hills, its staff and volunteers from claim or liability due to sickness or injury of my child. I attest to the fact that the above named child is covered by an insurance policy covering illness and injury. I accept all financial responsibility concerning any medical emergency. PLEASE LIST PARENT/GUARDIAN NAME:
DATE:
List any medical illness or allergies and what action we are to take until you are contacted:
Please answer the simple math question below to submit the form.
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 Colonial Hills Church 7701 Hwy 51 North, Southaven, MS 38671 (662) 393-2445
 
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