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Kids' Club 2021

Ultimate Olympics

July 26-30 ~ 6:00 p.m. - 8:00 p.m.
Celebration Sunday, August 1^st 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:

Parent/Guardian Name(s):

Address:

Home/Primary Phone: Grade Entering Fall 2021:

Email Address:

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

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 #:

I authorize emergency transport as defined in this section and agree that my electronic signature below acts as my legally binding signature.

Parent or Guardian:

Date: April 25, 2024

Authority to Pick-Up/Dismiss

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

(Mother/Guardian):
(Father/Guardian):
Name: Relationship:
Name: Relationship:

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

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.

I consent

Parent or Guardian:

Student Photographs

Photographs of students engaged in Kids’ Club 2019 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.

I agree to all consents listed in this form, the privacy policy listed at https://westsub.org/privacy, and that all information contained in this registration form is accurate. By signing below, I agree that my electronic signature acts as my legally binding signature.

Leave this empty:

Your legal name

Your email address

Timestamp

Audit

July 1, 2021 6:33 pm CDT

Kids' Club 2021 Uploaded by Brian Semrau - [email protected] IP 98.253.116.65

July 1, 2021 6:53 pm CDT

Barb Granrath - [email protected] added by Brian Semrau - [email protected] as a CC'd Recipient Ip: 98.253.116.65

July 1, 2021 7:07 pm CDT

Barb Granrath - [email protected] added by Brian Semrau - [email protected] as a CC'd Recipient Ip: 98.253.116.65