2026-2027 Kids Club Parent/Guardian Consent
Child's Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Non-binary
Grade in September (enter "0" for Kindergarten)
*
Please indicate the grade your child will be entering in the 2026-2027 school year.
Name of Child's School
*
School Location (Town)
*
Parent/Guardian A Name
*
First Name
Last Name
Parent/Guardian A Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian A Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian A Email
*
example@example.com
Parent/Guardian B Name
First Name
Last Name
Parent/Guardian B Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian B Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian B Email
example@example.com
I give my permission for my child's photograph & name to be used in any advertising print medium or website including the Kids Club Facebook page.
*
Yes
No
I give my permission for my child's name, address and telephone number to be printed in the Kids Club Student Directory to be released by the JCC. I hearby agree that I will not permit any other person other than my child's parent and/or legal guardian to have access to this directory.
*
Yes
No
I give permission for my child to participate in scheduled/unscheduled spontaneous field trips during the time he/she is in the care of, and under the direction of the staff of the JCC. In most cases, an individual permission slip, prior to each event, will be distributed for me to sign. However, from time to time, we may take spontaneous walking trips to several places nearby.
*
Yes
No
In the event of an emergency requiring medical treatment, if the JCC cannot reach either parent(s)/guardian or emergency contact person, I authorize the JCC to act as a Guardian for my child according to its best judgement.
*
Yes
No
Insurance Company
*
Hospitalization Policy #
*
Insurance Company Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Signature of Parent/Guardian
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: