Clubhouse and ClubGrub Registration Form

We're excited to have your kids join us for 90 minutes of fun during our family-oriented Kids Clubhouse at Brock Wes! Please enter the email address you'd like use in order to receive a copy of this registration form. When: Thursday nights from 6:30 to 8:00 Where: 33 Central Ave. W, Brockville, ON, K6V 4N4 Contact us at (613) 342-4566 or brockweskids@gmail.com

Your name *

Email address *

Phone number *

May we communicate with you via text? *

Yes

Address *

Photo Permissions *

I give permission for my child's photo to be shown in the private "Brock Wes Kids" Facebook group for parents/relatives of kids in the program (this is NOT open to the public)

Yes

Photo Permissions (Public website) *

I give permission for my child's photo to be shown on the Brockville Wesleyan church website (this IS open to the public)

Yes

Emergency Contact Information

Name *

Phone number *

Name

Phone number

Children's Information

Name *

Age *

Grade *

School

Birthdate *

Are there any Allergies or Medical information that we need to know in order to care for them well? *

Does your child need extra adult help to function well at school? If yes, please describe any difficulties they typically have. *

Do you have a second child to register?

Pick-Up Information

Please List ALL individuals with permission to pick-up or drive your child(ren) home: *

Please list any individuals below who may NOT pick up your child(ren) *

Please type N/A if not applicable

Is there any other information that you would like to share with us?

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