NEON Party

Neon Party

Saturday, January 21st 8-10pm
Participant Name

First NameLast Name
Age & Grade (For students in grades 6-8)
Parent's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Email
example@example.com
Phone Number
Please enter a valid phone number.
Emergency Contact Name (authorized to pick up teen)

First NameLast Name
Emergency Contact Phone #
Please enter a valid phone number.
Cost: $20 per registration

Glow goodie bags for the first 75 registered!

PLEASE CALL THE BCC AT (763) 200-4271 TO COMPLETE PAYMENT.

REGISTRATION IS NOT CONFIRMED UNTIL PAYMENT HAS BEEN RECEIVED.
Statement of Release

I understand that my child must stay for the duration of the program and that I MUST PICK MY TEEN UP PROMPTLY AT 10PM.

Permission granted for participant to be included in pictures and publicity, (ex. brochures, flyers, Facebook etc.), connected with the BCC with no compensation to me. All pictures and video remain the property of the BCC.

I agree to release the Becker Community Center, City of Becker, their employees and leaders of all liability related to accidents or injuries, which myself or member of my family might incur while participating in the above mentioned activity. Participants in the above mentioned activity are not covered under the Becker Community Center's or City of Becker's medical insurance policy.
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