Parents' Night Out Registration
Please fill out a seperate form for each child.
Child's Name:
*
First Name
Last Name
Child's Birthdate:
*
-
Month
-
Day
Year
Date
Allergies:
*
Medications:
*
Other Physical, Mental or Emotional Needs We Need to be Aware of:
*
Parent's Name:
*
First Name
Last Name
Parent's Phone Number:
*
Please enter a valid phone number.
Parent's Email Address:
*
example@example.com
Parent's Name:
First Name
Last Name
Parent's Phone Number:
Please enter a valid phone number.
Parent's Email Address:
example@example.com
Emergency Contact's Name:
*
First Name
Last Name
Emergency Contact's Phone Number:
*
Please enter a valid phone number.
I give permission for the staff of Great Bridge Presbyterian Church to use my child's image, with no identifying information on our website and/or social media accounts.
*
Yes
No
I give permission for my child, listed above, to participate in the activities sponsored by the Children's Ministry of Great Bridge Presbyterian Church. Should emergency medical treatment be necessary and I am unable to be contacted, I authorize accompanying adult sponsors to act on my behalf and approve medical treatment.
*
Submit
Should be Empty: