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Teen Game Night Registration June 24th at 5:30pm-7:00pm
Please note: This event is only for Antioch residents.
It's that time again, we invite all youth ages 12-18 to our Teen Game Night on June 24th from 5:30pm-7:00pm. You can enjoy free games, and food surrounded by old, and new friends. We hope to see you then.
Please note: A parent/guardian's signature is required to sign their child out at the end of the event. Every youth must stay for the whole event, if you need to leave early you will need to have a parent/guardian sign you out, or have verbal confirmation. Please come to the front entrance to sign out your youth. Please contact youth@antiochca.gov if you have any questions or concerns.
Youth Name:
*
First Name
Last Name
Youth Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Youth E-mail:
example@example.com
Birth Date:
*
-
Month
-
Day
Year
Date
Age:
*
Please Select
12-15 years old
16-18 years old
What school do you attend?
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contacts:
*Please fill out who we could contact incase of an emergency.
1. Parent/Guardian name:
*
First Name
Last Name
Parent/Guardian Phone Number:
*
Format: (000) 000-0000.
Parent/Guardian E-mail:
*
example@example.com
2. Parent/Guardian name:
First Name
Last Name
Parent/Guardian Phone Number:
Format: (000) 000-0000.
Parent/Guardian E-mail:
example@example.com
Allergy Information:
*Please include any allergy or dietary restrictions.
Do you have any allergies or dietary restrictions? If so, please list them down below and include what steps to take when encountering an allergic reaction:
*
Designated Pick-up Information:
*Please note: Youth will be released to parent/guardians, or designated pick-up adults only.
1. Designated pick-up Name:
*
First Name
Last Name
Designated Pick-up Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
2. Designated pick-up Name:
First Name
Last Name
Designated Pick-up Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
By checking this box I hereby authorize the City of Antioch, its affiliates, and their respective employees, agents, volunteers, and/or contractors ("City") to photograph or otherwise record my likeness or that of the below-named individual under 18 years of age. I further grant the City the irrevocable, perpetual and unrestricted right and permission to, use, re-use, publish, and republish my likeness in photographs, pictures, videos or other medium in any and all of its publications, including, without limitation, web-based publications and social media and such other medium as the City may desire. I understand and agree that all photos, videos, or other medium featuring my likeness will become City property, and will not be returned.
*
I have read and understand this waiver.
Submit
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