Kids' Club 2021
July 26-30 ~ 6:00 p.m. - 8:00 p.m.Celebration Sunday, August 1st at 10 a.m.
Child's Information (one form per child)
Date of Birth:
Home/Primary Phone: Grade Entering Fall 2021: K12345678
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:
Contact Person #2:
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:
Date: June 9, 2023
Authority to Pick-Up/Dismiss
The following individuals are authorized to pick up my child from WSCC.
My child has my permission to leave Kids' Club by him/herself (i.e. to walk home, bike home, etc.): NoYes
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.
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.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Kids' Club 2021
Agree & Sign