Parents Night Out

Parent's Name

Children's Names and Ages

Allergies or Other Concerns (If none, type N/A)

Phone

This address will receive a confirmation email

Address

Second Parent/Caregiver Name

Second Parent/Caregiver Phone

Second Parent/Caregiver Email

This address will receive a confirmation email

Second Parent/Caregiver Address

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Hospital of Choice

How did you hear about this event?

RELEASE: We realize that no activity is without the possibility of unforeseen hazards which could result in injury to an individual. By signing this form, and in consideration your child named above being allowed to participate, you, as a parent, guardian or other responsible party, agree to assume the risks and hazards which are inherent in this kind of activity. You also agree to absolve and hold harmless the sponsoring organizations and their representatives for damage, loss, injuries or death to the child for whom you sign. I further give my permission for the use of any photo or likeness of my child to be used by the sponsoring organizations for their use in promotional materials. I give my child, named above, permission to participate in this activity, and give my permission to the leaders of this function to authorize any treatment deemed necessary by a licensed physician due to accident or illness during this activity.

I Agree

Parent/Caregiver Electronic Signature (Type Full Name)

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

Friday, December 13 from 5-7:30 PM

Children and Youth Ministry Leaders are teaming up to babysit the kids while you’re out on a date! Drop off your kids, ages 6 months to 5th grade, and enjoy a night out while helping raise funds for their Winter Extreme Conference.

Cost is $20 for the first child and $10 for each additional child.

Parents Night Out

Description

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