March KNO

March KNO Registration Form

Fill out the form carefully for registration
Join Cale and friends for an evening of games, activities, crafts, pizza and so much fun! Please have your child bring a water bottlle. And if they don't like pizza, maybe something else they will eat.

Please let us know if your child requires any specific modifications or instructions (i.e. allergies, needs, etc.)

Payment can be made via cash or check to the Town of Fairfax or Venmo @FairfaxPR.

$25 for one; $40 for 2: $55 for 3
Child's Name

First NameMiddle NameLast Name
Child's Age
Parent 1 Name

First NameLast Name
Parent 2 Name

First NameLast Name
Parent 1 Mobile Number
Parent 2 Mobile Number
Parent Email
example@example.com
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, INDEMNITY, AND PARENTAL CONSENT AGREEMENT

I hereby release and discharge the Town of Fairfax, it's agents, employees, staff members, directors, and volunteers from any claims, responsibilities or liabilities for injuries or harm incurred as a result of my child's involvement as a participant in Kids Night Out through the Town of Fairfax.

I accept that allowing my child to participate in educational, instructional or recreation activities includes risks. These activities may be led or conducted by staff, contracted staff or others, and may include but are not limited to: Interactive games and other sporting activities; socializing; outdoor excursions; other chores; use of any equipment, in our facilities or on our premises.
Signature

Clear
Date

MonthDayYear
Date
MEDICAL RELEASE

I hereby grant consent to any and all health care providers designated by the Town of Fairfax to provide my child with any necessary medical care as a result of any injury or illness. This consent includes First Aid and CPR administered by staff of the Town of Fairfax and transportation by Fairfax Rescue to the hospital.

If an emergency should arise, I understand that a thorough effort will be made to contact me or or an emergency contact before action is taken, but I agree to accept any expense associated with such an emergency if it is not possible to contact me in advance of treatment.
Signature

Clear
Date

MonthDayYear
Date
PICTURE / VIDEO WAIVER

I give my consent and authorization for my child to be photographed while participating in the Fairfax Kids Night Out. By willingly signing below, I grant the Town of Fairfax permission to use photographs and videos taken during these events. Pictures and videos may be used for up to 10 years after the date they were captured.
Signature

Clear
Date

MonthDayYear
Date
Additional Comments
Should be Empty:

March KNO Registration Form