Kids' Club Enrollment - Fall 2018
Ainsworth Community Church, 318 North 4th Street, Ainsworth, IA 5220
For more information: Call Jan at 319-330-6175 or Karen at 319-430-0496
What is the name/s of youth enrolling in Fall 2018 Kids' Club?
Gender of each child - Male or Female
Date of Birth of each child
Grade entering in Fall 2018
Name and Phone Number of parent or adult to call in case of emergency
Is there anyone you do not wish to pick up your child?
If yes, please list name/s below
Washington County Hospital
UIHC - Iowa City
Mercy Hospital - Iowa City
Please list foods to be avoided and/or known allergies for each child:
Please give any information you believe to be helpful to staff in understanding and caring for your child.
In the event that my child may require medical and/or surgical care while I am unable to be reached, I hereby give consent to Ainsworth Community Church to act o my behalf to authorize medical and/or surgical treatment for my child. I agree to pay all cost and fees contingent on any emergency medical care and/or treatment for my child as secured or authorized under this consent
Occasionally, photos of students are included on our church website (
) and Facebook page(Ainsworth Community Church). We do NOT include the name of your child or 'tag' them in the picture.
YES, Ainsworth Church DOES have permission to use images of my child on the church website and Facebook page.
NO, Ainsworth Church DOES NOT have permission to use images of my child on the church website and Facebook page.
Send me a copy of my responses.
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