West Suburban Community Church in Elmhurst, IL

Kids' Club 2021


Ultimate Olympics

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

  Parent or Guardian:  

Date: September 27, 2021

 

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.):  

 

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. 

  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.

 

Leave this empty:

Signature arrow


Signature Certificate
Document name: Kids' Club 2021
lock iconUnique Document ID: 8d736b36abefc195f04f0c8597a9fb0297baccdf
Timestamp Audit
July 1, 2021 6:33 pm CDTKids' Club 2021 Uploaded by Brian Semrau - [email protected] IP 98.253.116.65
July 1, 2021 6:53 pm CDTBarb 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 CDTBarb Granrath - [email protected] added by Brian Semrau - [email protected] as a CC'd Recipient Ip: 98.253.116.65