The Scoop: A DIY Ice Cream Social Registration
Register for our Spring Break HQ event at Churchland Branch Library. Ages 12-17. Parent or guardian must fill out this form to consent for participant registration.
Event Details
Date: April 9th. Location: Churchland Branch Library-4934 High St W, Portsmouth, VA 23703. Ages 12-17. Time: 4:00pm-5:30pm. For questions, call 757-686-2538
Participant's Full Name
*
First Name
Last Name
Participant's Age
*
Other Participants and Their Age
If not applicable, put N/A
Parent/Guardian's Full Name
*
First Name
Last Name
Parent/Guardian's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian's Email Address
example@example.com
By registering for this event, the parent or guardian agrees to waive any responsibility or liability of the Churchland Branch Library and its staff for any injuries, damages, or losses that may occur during the event.
Does the participant have any food allergies?
*
No
Yes (please specify below)
If yes, please list all food allergies and any necessary precautions.
The program cannot be modified for allergies. If you still wish to proceed, please be aware of this policy.
Emergency Contact Name (put N/A for this box if it's the same parent or guardian listed previously)
*
First Name
Last Name
Relationship to Participant
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Signature (Required for consent)
*
How did you hear about us?
Facebook
Nextdoor
Word of Mouth
School
Other
Which flavor ice cream do you want?
Chocolate
Vanilla
Strawberry
I hereby grant permission for the participant named above to be photographed or recorded during The Scoop: A DIY Ice Cream Social event. Photos/videos may be used by the library for promotional purposes. I understand no compensation will be provided, and images may be used in print or digital media. I release the library and its representatives from all claims related to the use of these images.
Parent/Guardian Signature (Required for consent)
*
Register
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