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Crossroads Kids Club
Crossroads Kids Club is a free, fun, faith-based program open to children in grades K - 5th.
Thompson School | Rockford, IL.
Location: Thompson School Gym

When: Tuesdays, 2:10 - 3:45pm | September 26, 2017 - May 1, 2017

Church sponsor: Calvary Christian Church | 5455 Charles Street. | Rockford

Club Leader: Joel Harrison | 815-298-5744 | cccryouth@gmail.com

Child's Name *
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Address *
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City and Zip *
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Child's Date of Birth *
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Gender *
Child's Grade *
T-Shirt Size *
Your Name *
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Your Relationship to the Child *
Primary Phone Number *
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Primary Phone Type *
Secondary Phone Number
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Secondary Phone Type
Email *
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After Club, shall we (Choose One) *
1. Authorized Pick Up People (Name and Relationship)
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2. Authorized Pick Up People (Name and Relationship)
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3. Authorized Pick Up People (Name and Relationship)
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Please List any allergies to food or others you child may have. If none, please write "none." *
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Are there any physical limitations, restrictions or other concerns you have about your child participating in Crossroads Kids Club? If none, please write "none." *
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Waiver & Assumption of Risk
IMPORTANT INFORMATION, WAIVER OF ALL CLAIMS AND ASSUMPTION OF RISK

Crossroads Kids Club is an organization that licenses an after school program to local churches. Each church is completely responsible for their individual program, including the selection and screening of staff and program activities. The sponsoring church, listed above (hereinafter “the Church”) is responsible for the Crossroads Kids Club program (hereinafter “CKC”) also described above. The Church is committed to conducting all of its programs, activities and field trips in a safe manner. Because the Church holds the safety of all participants in high regard, all staff members insist that students follow all safety rules. Even so, students and parents must be aware that there is an inherent risk of injury when choosing to participate in recreational and social activities. As the parent/guardian, you are solely responsible for determining if your minor child is physically, emotionally, and intellectually fit to participate in the Church’s CKC program. Also, students may be photographed or videotaped in connection with their participation in the Church’s CKC program, and all claims or rights to such photos or video recordings are released by signing below. The Church or Crossroads Kids Club may use these recordings and photos for any purpose that they deem appropriate.

I understand that by registering my child to participate in the Church’s CKC program I am expressly assuming the risk and all legal liability that arises or may arise out of such participation. I also understand that I am waiving and releasing all claims for injuries, damages or losses, which my child might sustain as a result of participating in any and all activities connected with and associated with said programs/activities. I recognize and acknowledge that there are certain risks of physical injury to participants in these programs/activities, and I voluntarily agree to assume the full risk of any and all injuries, damages and losses, regardless of severity, that my minor child may sustain as a result of said participation except in cases of gross negligence or intentional misconduct. I further agree to waive and relinquish all claims that I, my successors, assigns, or my minor child may have (or which may accrue to me, my successors, assigns, or my child) as a result of participation in these programs/activities against the Church, its affiliated or partnering churches, boards of directors, volunteers, employees and associated companies. I do hereby fully release and forever discharge the Church from any and all claims for injuries, damages or loss that my minor child may have or which may accrue and arising out of, connected with, or in any way associated with these programs/activities, except in cases of gross negligence or intentional misconduct.

By signing below I am registering my child for the Crossroads Kids Club program. I understand that it is a faith-based program, that it is my discretion to enroll my child in this program, and I have read the terms and conditions above regarding my child’s participation in CKC. I also understand that my child will be expected to conform to the CKC code of conduct and if s/he does not, I will be notified and they may be removed from the CKC program.

I, the undersigned, agree to the terms above.

Typing your name below, to electronically submit your form, means you understand and agree to the terms above. *
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