• • Name of Child #1
    
    First
    
    Last
• • Age/Grade of Child #1 *
    ...2 Yrs (by 8/31/12)3 Yrs (by 8/31/12)4 or 5 yrs (NOT yet in Kinder)Kindergarten1st2nd3rd4th
    
• • Child #1 Date of Birth
    
    
• • Name of Child #2
    
    First
    
    Last
• • Age/Grade of Child #2
    ...2 Yrs (by 8/31/12)3 Yrs (by 8/31/12)4 or 5 yrs (NOT yet in Kinder)Kindergarten1st2nd3rd4th
    
• • Child #2 Date of Birth
    
    
• • Name of Child #3
    
    First
    
    Last
• • Age/Grade of Child #3
    ...2 Yrs (by 8/31/12)3 Yrs (by 8/31/12)4 or 5 yrs (NOT yet in Kinder)Kindergarten1st2nd3rd4th
    
• • Child #3 Date of Birth
    
    
• • Parent (s) Name *
    
    First
    
    Last
• • Parent (s) Name
    
    First
    
    Last
• • Address *
    
    Street Address
    
    Other Address (optional)
    
    City
    ...AlabamaAlaskaAlbertaArizonaArkansasBritish ColumbiaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew BrunswickNew HampshireNew JerseyNew MexicoNew YorkNewfoundlandNorth CarolinaNorth DakotaNova ScotiaOhioOklahomaOntarioOregonPennsylvaniaPrince Edward IslandQuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingYukon Territory
    State/Province
    
    Zip/Postal Code
    
    Region (optional)
    ...United StatesCanadaJapanUnited KingdomAustraliaGermanyFranceSwitzerlandItalyNetherlandsAlbaniaAlgeriaAmerican SamoaAndorraAnguillaAntarticaAntigua & BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBotswanaBouvet IslandBrazilBritish Indian Ocean Terr.Brunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslColombiaComorosCongoCook IslCosta RicaCote D'IvoireCroatiaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEstoniaEthiopiaFaeroe IslandsFalkland Isl. (Malvinas)FijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern Terr.GabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernsey C.I.GuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslHondurasHong KongHungaryIcelandIndiaIndonesiaIrelandIsle of ManIsraelItalyJamaicaJapanJersey C.I.JordanKazakhstanKenyaKiribatiKorea Republic ofKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLiechtensteinLithuaniaLuxemborgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslMartiniqueMauritaniaMauritiusMexicoMicronesiaMoldova Republic ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherland AntillesNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslNorthern Mariana IslNorwayOmanPakistanPalauPanamaPanama Canal ZonePapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts & NevisSaint LuciaSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSt. HelenaSt. Pierre and MiquelonSt. Vincent & GrenadinesSurinameSvalbard & Jan Mayen IslSwazilandSwedenSwitzerlandTaiwanTajikistanTanzania United RepublicThailandTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslTuvaluU.A.E.U.S.Minor Outlying IslUgandaUkraineUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican City StateVenezuelaViet NamVirgin Isl (British)Virgin Isl (U.S.)Wallis & Futuna IslandsWestern SaharaYemen Republic ofZaireZambiaZimbabwe
    Country
• • Email
    
    
• • Phone Number (that could be reached during AWANA) *
    
    
    
    
    
    
• • Please list any allergy, health, or behavioral concerns for each child. 
    
    

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