5th Quarter

5TH QUARTER

Friday, October 6th 8:30pm - 11pm
Participant Name*

First NameLast Name
Age*
Grade*
*

MEMBERNON-MEMBER
Parent's Name*

First NameLast Name
Parent's Email*
example@example.com
Parent's Phone Number*
Emergency Contact Name #1 - (authorized to pick up child)*

First NameLast Name
Emergency Contact #1 Phone Number*
Activity/Activities Registering For:*

5TH QUARTER - Friday, October 6th, 2023
COST: $10/PERSON BEFORE 9/29 $15/PERSON STARTING 9/30

PLEASE CALL THE BCC TO COMPLETE PAYMENT (763) 200-4271. PAYMENT & REGISTRATION MUST BE COMPLETE BEFORE CHILD(REN) MAY ATTEND THE EVENT. WALK-INS ARE ACCEPTED BUT PRE-REGISTRATION IS ENCOURAGED! THANK YOU!
Statement of Release

I understand that my child must stay for the duration of the program and that I MUST PICK MY CHILD UP BEFORE 11PM.

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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5TH QUARTER