KIC Registration Form 2021-2022
Event Timing: September, 2021- April, 2022
Event Address: 1103 F Ave. Grundy Center, IA 50638
Contact us at (319) 824-3557 or office@alcgc.org
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Name of Child/Youth *
Grade In School *
Age *
Please Note:  Classroom teachers of children age 2nd grade and younger classroom will bring them to the entry.  They will not be released without someone to pick them up each week.  We provide this space below for parents to designate an alternate person when that is necessary. This person is authorized to pick up my child from KIC when I am not available:
Birthdate *
MM
/
DD
/
YYYY
Mailing Address *
Parent Name *
Primary Phone *
Secondary Phone
Youth Cell Phone
Parent Email Address *
Second Email Address
Youth Email Address
Any known food allergies:
Is there anything else we should know about your child? (medications, special needs, physical, emotional or behavioral issues)
Emergency Contact- in the event that a parent cannot be reached and there is a medical situation (allergic reaction, injury, etc.) with your child, who should be contacted? (Please include name and phone number of emergency contact and relationship to child.) *
Any cell phones on this registration will be included in text message alerts to remind you of upcoming events or weather cancellations.  Please check this box to opt out.  (Standard text messaging rates will apply.)
Each year a new form for each child will be needed.  Your child will receive their name tag when this form is returned.
Below, please check I agree/I disagree that photos of my child may be included in congregational publicity, including the internet, with the understanding that names will NOT be attached by congregational representatives.  In clicking agree in this box, I am electronically signing my name. *
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