Youth All-Night Experience Registration

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Youth Up All Night Experience

Hosted by Mary Lou's Heart Foundation, M.A.D., and Life After ReleaseWebsite: www.marylousheart.comEmail: info@marylousheart.com Register your child for the Youth All-Night Experience on June 12, 8 PM - 8 AM.Venue: Creative Suitland, 4719 Silver Hill Rd, Suitland, MD day -of event contact: (301) 798-7933
Participant Information
First Name
Last Name
Date of Birth

MonthDayYear
Date
Age
Grade in School
Gender
Participant Email Address
example@example.com
Participant Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
T-Shirt Size
Parent/Guardian Information
Parent/Guardian First Name
Parent/Guardian Last Name
Relationship to Participant
Parent Email Address
example@example.com
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
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Relationship to Participant
Medical Information
Please list any allergies or medical conditions we should be aware of
Do you have any allergies?
Allergy details
Do you have any medical conditions?
Medical condition details
Current medications
Primary care physician name and phone
Dietary restrictions
PARENTAL/GUARDIAN CONSENT: I certify that I am the parent or legal guardian of the participant named on this registration. I have full legal authority to enroll this child in the Youth All-Night Experience hosted by Mary Lou's Heart Foundation, M.A.D, and Life After Release. I have read and understand all information about the event, including its location, schedule, activities, and rules. I voluntarily give my consent for my child to participate in all event activities, including games, group activities, worship/programming, meals, and overnight supervision at Creative Suitland. I confirm that all information I have provided on this registration is true and accurate to the best of my knowledge.
MEDICAL WAIVER AND HEALTH ATTESTATION: I attest that my child is in good general health and is physically able to participate in the activities of this overnight event. I have disclosed all known allergies, medical conditions, medications, and dietary needs on this form. I understand that Mary Lou's Heart Foundation, M.A.D, and Life After Release, event staff, and volunteers are not medical professionals and will administer first aid only as reasonably needed. I authorize event staff to administer over-the-counter medications (such as acetaminophen, ibuprofen, or antihistamines) to my child if needed, unless I indicate otherwise below. In the event of illness or injury during the event, I authorize event staff to contact me immediately and, if I cannot be reached, to seek appropriate medical care for my child. I release Mary Lou's Heart Foundation, M.A.D, and Life After Release and its partners from any liability arising from medical decisions made in good faith on behalf of my child during the event.
If you do NOT want event staff to administer over-the-counter medications to your child, please list any restrictions here:
TRANSPORTATION CONSENT: I understand that my child may be transported by event staff or volunteers in the event of a medical emergency or other urgent circumstance. I consent to such transportation and release Mary Lou's Heart Foundation, M.A.D, and Life After Release, the venue, and all partners, drivers, and volunteers from any liability arising from such transportation.
COMMUNICABLE DISEASE ACKNOWLEDGMENT: I understand that participation in a group event involves the risk of exposure to communicable illnesses, including but not limited to colds, flu, and other contagious conditions. I assume this risk on behalf of my child and agree not to send my child to the event if they are showing symptoms of illness within 48 hours of the event.
BEHAVIORAL EXPECTATIONS: I understand that Mary Lou's Heart Foundation, M.A.D, and Life After Release reserves the right to dismiss any participant whose behavior is disruptive, unsafe, disrespectful, or otherwise inconsistent with the values and rules of the event. In the event of dismissal, I agree to pick up my child promptly from the venue at my own expense, regardless of the time of night.
PERSONAL PROPERTY: I understand that Mary Lou's Heart Foundation, M.A.D, and Life After Release, Creative Suitland, and all event partners are not responsible for any lost, stolen, or damaged personal property (including phones, electronics, clothing, or other belongings) brought to the event by my child.
Electronic Signature
Parent/Guardian Electronic Signature
Date of Signature

MonthDayYear
Date
Printed Name of Parent/Guardian

First NameLast Name
Additional Information
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Youth Up All Night Experience

Participant Information

Parent/Guardian Information

Emergency Contact

Medical Information

Electronic Signature

Additional Information