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 #
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