Child's Name

Child's Age

Month

Day

Year

Parents Name

Street Address

Address 2

City

State

Zip Code

Phone Number

Other Number

Emergency contact person and phone number

Relationship to Child

Allergies or medical conditions

Home Church

Other Information

Do you want to be an adult volunteer?

We may be able to pick up your child at school or their bus stop. Please let us know if you would like either of these options and we will contact you.

In the event of an emergency, I authorize whatever medical treatment is deemed necessary for my child (listed above), while attending Kilgo Kids Crew after school program. I understand and give permission for my child to participate in the age appropriate kitchen/cooking activities under close supervision of adults.