Kids Club Summer Enrollment Form

KIDS CLUB
Summer Enrollment Request Form
All information obtained is confidential and used strictly for Kids Club.
I would like to register my child(ren) for the Summer Childcare Enrichment program:
Mark Days of Attendance
Monday
Tuesday
Wednesday
Thursday
Friday
Requested Start Date:
Child(ren) Attending Kids Club
Birthdate
School Attending
Address
Address (if different than the child/ren)
Relationship to child/ren
E-mail Address
Home/Cell
H
Secondary Contact Phone #
Home/Cell
C
H
Primary Parent/Guardian's Employer
Secondary Parent/Guardian's Name
C
Primary Parent/Guardian Employer Phone#
Address (if different than the child/ren)
Relationship to child/ren
Primary Contact Phone #
Teacher
City, State, Zip
Primary Parent/Guardian's Name
Primary Contact Phone #
Grade
E-mail Address
Home/Cell
H
Secondary Contact Phone #
C
Home/Cell
H
Secondary Parent/Guardian's Employer
C
Secondary Parent/Guardian Employer Phone#
Please complete other side
Please list people that may pick-up your child/ren or be a emergency contact if primary or secondary
parent/guardian cannot be reached.
Emergency Contacts/
Pick-up Persons
Relationship
to Child
Primary Phone #
Secondary Phone #
Please intial next to each statement that is true.
I receive Child Care Benefits or DCFS assistance.
In case of medical emergency during Kids Club, I give my permission to the authorized
personnel to secure the necessary emergency care or services of a licensed physician or
medical facility.
I give Kids Club permission to photograph or videotape my child. Photographs are used for
special projects and activities. Kids Club does not use the photos for advertising or
marketing without written parent’s permission.
I have read and agree to the Kids Club rules and conditions as explained in the Kids Club
Client Handbook.
I give permission to Kids Club to acquire my child's birth certificate, health records and
IEP/504 plans from Woodstock CUSD#200 or I will provide copies myself.
Parent/Guardian signature
Date
Please return this form and registration fee made payable to :
KIDS CLUB
14126 W. South Street
Woodstock, Il 60098
Phone 815-338-0643
Fax 815-337-6126
E-mail: [email protected]
Office Use:
Intake Meeting Date/Time:
Registration Fee quoted:
Fees:
Public Assistance fees:
Pay monthly
Security Deposit quoted:
Pay weekly
Notes:
Fees Paid:
Amount
KCSHARED.FORMS.ENROLLMENT REQUEST FORM
Cash
Check #