Parents Night Out ATTENDEE

🌟PARENTS NIGHT OUT 🌟

"Take a Break, Make a Date! 🎄Let Us Entertain the Kids with Crafts & Cheer While You Enjoy Some Holiday Magic!"

🗓️ When: Saturday November 19th, 2025

⏰ Time: 7 PM TO 9 PM

📍 Location: AGilbert, AZ

🏠 Address: TBD

For a list of our upcoming events, check out our Events tab on Facebook or visit our website at www.asanow.org

With Gratitude,

Angela Teachout

Susan Woodruff

Anika Robinson

'Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has". Margaret Mead
We need to capture some important information to help coordinate care.

Please take a moment to fill this form out in it's entirety.

If you are in need of childcare, we ask that you please list children from youngest to oldest.

If a foster child leaves your home or a new one is placed, please let us know as soon as possible.

*Be sure to CONSENT, SIGN & hit the SUBMIT button along with your payment. An automatic confirmation email will be received*
Select Date to Attend*

Saturday, 11/19/25 7pm to 9pm
If you are a Foster or Kinship family, would you like to be considered to receive Free Food and Clothing?*

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Are you an (check all that apply)*

Unlicensed Kinship CaregiverLicensed Kinship CaregiverLicensed Foster CaregiverTribal Foster CaregiverCaregiver with Guardianship to Child with Child Welfare InvolvementFoster/Adoptive Family
Primary Caregiver's Name #1*

Last NameFirst Name
Primary Caregiver's Name #2

Last NameFirst Name
Current Address*

Street Address

CityPostal/Zip Code

COUNTY you reside in
Cell Phone Number*

Area CodePhone Number
Emergency Cell Phone Number (only required if childcare is needed)

Area CodePhone Number
E-mail*
Total Number of People Currently Living in the Home?*
Includes all Adults and Children
Number of Adults Living in the Home?*
(This includes adult children age 18 and over who are out of high school)
Total Number of Children Living in the Home?*
(Children under 18 and those over 18 who are still in high school)
Number of Foster, Tribal Foster, or DCS Guardianship Children Living in the Home?*
(This does NOT include non-DCS kinship or guardianship without DCS involvement.)
Number of Adopted Children Living in the Home?*
(Under 18 and those over 18 who are still in high school)
Number of Biological Children Living in the Home?*
(Under 18 and those over 18 who are still in high school)
Number of Non-DCS Kinship or Guardianship Children WITHOUT DCS Involvement Living in the Home?*
(Under 18 and those over 18 who are still in high school)
How many children will be in attendance ?*
How many of the total number of children in attendance are foster/tribal/DCS guardianship children?*
Based on family size, does your family fall below the following income levels: One (1) person: $20,385, Two (2) people: $27,465, Three (3) people: $34,545, Four (4) people: $41,625, Five (5) people: $48,705, Six (6) people: $55,785, Seven (7) people: $68,865, Eight (8) people: $69,945. Add $4,720 per additional household member.

YesNo
If you have a FOSTER, TRIBAL FOSTER, or DCS GUARDIANSHIP CHILD please click YES and enter their information first, otherwise click NO. If you do not need childcare for this event, please click NO.

YesNo

Click Here to register additional children OR complete registration
Continue with Sign-up

Yes, register more childrenNo, go to consent and submit form

Click Here to Consent
Liability Release - I do hereby release ASA Now, Jacobs Mission Community Center, their agents, employees, personal representatives, affiliates, and any and all persons, firms or corporations liable or who might be claimed to be liable, whether or not herein named, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, arising out of or in any way relating to injuries and damages, as a result of being present on Jacobs Mission Community Center. I recognize that there may be inherent risks associated with attending or participating in this event. You have been fully informed of your consent, waiver of liability, and release before entering the event.
I have reviewed, understand, and agree to comply with the above terms*

Agree
By attending or participating in this event, you consent to interview(s), photography, audio recording, video recording and its/their release, publication, exhibition, or reproduction to be used for news, web casts, promotional purposes, telecasts, advertising, inclusion on websites, social media, or any other purpose by ASA Now and Jacobs Mission Community Center. Images, photos, and/or videos may be used to promote similar ASA Now events in the future, highlight the event and exhibit the capabilities of ASA Now. You release ASA Now, its officers and employees , and all persons involved from any liability connected with the taking, recording, digitalizing, or publication and use of interviews, photographs, computer images, video and/or sound recordings. By entering the event premises, you waive all rights you may have to any claims for payment or royalties in connection with any use, exhibition, streaming, web casting, televising, or other publication of these materials, regardless of the purpose or sponsoring of such use, exhibiting, broadcasting, web casting, or other publication irrespective of whether a fee for admission or sponsorship is charged. You also waive any right to inspect or approve any photo, video, or audio recording taken by ASA Now, Jacobs Mission Community Center or the person or entity designated to do so by ASA Now. You have been fully informed of your consent, waiver of liability, and release before entering the event.
I have reviewed, understand, and agree to comply with the above terms*

Agree
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