Mysteries Among Us

July 24-28 ~ 6:00 p.m. - 8:00 p.m.
Celebration Sunday, July 30^th at 10 a.m.

Registration Form

For children entering K-8th Grade This Fall

Child's Information (one form per child)

Child's Name:  

Date of Birth: Date of Birth

Parent/Guardian Name(s):  

Address:

Home/Primary Phone:  

Grade Entering Fall 2023: K12345678 

Email Address:  

IMPORTANT: Does your child have any allergies or medical conditions the staff should know about? 

YesNo

If yes, please specify, and list medications and dosage (otherwise enter "n/a"):

Emergency Contact Information

Contact Person #1:  

Relation to child:  

Home/Primary Phone:  

Alt. Phone:  

Contact Person #2:  

Relation to child:  

Home/Primary Phone:  

Alt. Phone:

Permission to Transport

In the event of a medical emergency, we will call 911 for Emergency Services, including transport to the nearest hospital/clinic.  Please provide the following information and check below to authorize emergency transport.

Child's Insurance Provider:  

Policy #:  

Date: July 16, 2024

Authority to Pick-Up/Dismiss

The following individuals are authorized to pick up my child from WSCC.

1. (Mother/Guardian):  
2. (Father/Guardian):  
3. Name:     Relationship:  
4. Name:   Relationship:  

My child has my permission to leave Kids' Club by him/herself (i.e. to walk home, bike home, etc.): NoYes 

Parental Consent

I consent that my child, , is allowed to participate in West Suburban Community Church's Kids' Club program, and that my e-signature below acts as my legally binding signature. 

Student Photographs

Photographs of students engaged in Kids’ Club 2023 activities may be taken and used for in-church purposes (bulletin boards, slide shows, etc.). Your child’s picture may also be posted on the church website or the church social media page.  Your e-signature below acts as your consent.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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• Type In Signature
  

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

Insert Signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Signature Certificate

Document name: Kids' Club 2023

Unique Document ID: 32b2dfefba57f305ae901632309b84bddffe815f

Build. Track. Sign Contracts.

Timestamp	Audit
June 24, 2023 3:57 pm CDT	Kids' Club 2023 Uploaded by Brian Semrau - [email protected] IP 71.57.26.62
June 24, 2023 4:15 pm CDT	Barb Granrath - [email protected] added by Brian Semrau - [email protected] as a CC'd Recipient Ip: 76.136.238.5
June 24, 2023 4:15 pm CDT	Dennis Criser - [email protected] added by Brian Semrau - [email protected] as a CC'd Recipient Ip: 76.136.238.5
July 1, 2023 10:40 am CDT	Barb Granrath - [email protected] added by Brian Semrau - [email protected] as a CC'd Recipient Ip: 50.196.223.133
July 1, 2023 10:40 am CDT	Dennis Criser - [email protected] added by Brian Semrau - [email protected] as a CC'd Recipient Ip: 50.196.223.133

This audit trail report provides a detailed record of the online activity and events recorded for this document.

https://westsub.org/

Audit Trail Serial# c916546073a32676b789a77f3f8cdc90