Kish Kids Club
Sunday Night Program Winter 2023
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Email *
For students Pre K (age 3) to completed Grade 5
January 22 through April 2, 2023   5:30pm to 7:00 pm at Kishwaukee Church
Family Last Name *
(use child's last name)
Parent's Name *
Contact Information
Street Address *
City *
Zip Code *
Email Address *
Used only to receive Kish Kids Club information
Phone Number *
Example 815-123-4567
Emergency Contact (Full Name) *
relation to family *
Emergency Contact Phone Number *
Example 815-123-4567
Kish Kids Club Sunday
Do you have a home church *
Child(ren) to be enrolled
Select age 3 by 6/1/22 or select the grade recently completed.
First Child's Name (ex: John Smith) *
First Child's Grade *
Second Child's Name (ex: John Smith)
Second Child's Grade
Clear selection
Third Child's Name (ex: John Smith)
Third Child's Grade
Clear selection
Fourth Child's Name (ex: John Smith)
Fourth Child's Grade
Clear selection
Medical Information
Allergy Alerts & Medical Conditions *
List Child's Name and allergy, medical, or other pertinent information. State NA (Not applicable) if there are no allergy or medical conditions to note.
Physician's Name *
Preferred Hospital *
People who may pick up your child(ren) *
KKC Waiver
I allow the undersigned to the following: *
List all children attending
May we have permission to photograph your child? *
May we have permission to use your child's/children's photo for the purpose of promotion? *
Pictures may appear on the Kishwaukee EPC Website or church related brochures/newsletters.
CHURCH LIBRARY CONSENT:  We, the parents (legal guardians), of the child (children) registered above, do hereby consent to our child (children) use of the church library offered at Kishwaukee Evangelical Presbyterian Church, following the materials loaning guidelines of the library. *
If you and the physician specified above cannot be reached in an emergency, and in the judgment of church leaders immediate and/or hospital attention is indicated, do you authorize responsible church leaders to send your child, properly accompanied, to an available hospital or physician? *
PARENTAL AGREEMENT: We, the parents (legal guardians), of the child (children) registered above, do hereby consent to our child (children) participating in the Kish Kids Club program offered at Kishwaukee Evangelical Presbyterian Church, Sunday nights from January 22 to April 2, 2023. We assume all risks and hazards incidental to such participation and do hereby release, waive, absolve, indemnify, and agree to hold harmless Kishwaukee Evangelical Presbyterian Church, their leaders, volunteers, and any persons supervising or assisting or in any way connected to KKC or any claim arising out of or injury to our child (children) as a result of participating in KKC. *
I understand that my typed signature serves as my written signature.
Date *
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