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
Email address *
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
Hospital Preference *
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. *
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