PayPal Sponsorship Form

"ONLY 137 SEATS AVAILABLE"

Premium Private Screening groups receive exclusive concession discounts when purchased at least two weeks before the event date. A minimum purchase of 20 per combo is required.

$7 Small Combo: 1 small fountain drink + 1 small popcorn (regularly valued at $11.40)

$8 Hot Dog Combo: 1 medium fountain drink or bottled water + 1 Angus hot dog (regularly valued at $10)

Field Trip Date
SATURDAY, June 17, 2023
10:00 AM

Tickets are Pre-Order only

Location:

Victorville Mall Cinemark

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How Many Attending*

Buyer E-mail (this is how we will notify you)*

example@example.com

Phone Number*

Please enter a valid phone number.

City where you live?*

My Products

Little Mermaid $8.25Single Movie Ticket

$8.25 Quantity

$7 Small Combo: 1 small fountain drink + 1 small popcorn (regularly valued at $11.40+)$7 Small Combo: 1 small fountain drink + 1 small popcorn (regularly valued at $11.40+)

$7.00 Quantity

$8 Hot Dog Combo: 1 medium fountain drink or bottled water + 1 angus hot dog (regularly valued at $10+) 8.00$8 Hot Dog Combo: 1 medium fountain drink or bottled water + 1 angus hot dog (regularly valued at $10+)-

$8.00 Quantity

Total

$0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Household Number*

Over 62*

AGREEMENT AND RELEASE OF LIABILITY I, the undersigned, understand the following: * Rock'n Our Disabilities Foundation does not provide participants with medical insurance or treatment for injuries. * I agree to hold harmless and release Rock'n Our Disabilities Foundation, its officers, agents, and employees from all liability arising from or related to my participation in Rock'n Our Disabilities Field Trips for Special Needs families program activities. This release includes, but not limited to, all liability for death, personal injury, or property damage resulting from the active or passive negligence of the Rock'n Our Disabilities Foundation or its agents or any defective or hazardous condition of any property or equipment owned, operated or maintained by the Rock'n Our Disabilities Foundation. The Agreement and Release of Liability are signed with the full knowledge of all members representing your party in the event. In ADDITION, the undersigned certifies that the foregoing application has been read and understood and any statements made in connection with the application are true and accurate. The applicant agrees to comply with all the rules and regulations established by Rock'n Our Disabilities Foundation as stated on this field trip form.

Signature for Release of Liability*

Clear

Private Movie Screening for RODF Families