Parents Night Out February 15th 2019
Number of children you are registering on this form (1-3)
*
Child's Name: (First/Last)
*
Age:
Date of Birth:
Please select a month
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Month
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2nd Child's Name: (First/Last)
Age:
Date of Birth:
Please select a month
January
February
March
April
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December
Month
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Day
Please select a year
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Year
3rd Child's Name: (First/Last)
Age:
Date of Birth:
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
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1929
1928
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1924
1923
1922
1921
1920
Year
Parent or Guardian: (First/Last)
Home Address:
Apt.
City:
Zip:
Home Phone:
*
Alternate Phone:
E-mail:
*
In Case of Emergency Contact:
Emergency Contact's relation to Child:
Emergency Contact Phone:
Emergency Contact Aternate Phone:
Any Medical Concerns:
Electronic Signiture
*
Please type guardians legal name and check below to complete electronic signiture
Medical and Liability Release
*
I herby electronicly sign granting permission for my child to participate in the Edgewater Lutheran Church Parents NIght Out, February 15th 2019. I understand all reasonable safety precautions will be taken at all times by Edgewater Lutheran Church durring the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Edgewater Lutheran Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form. I understand that in the event medical attention is needed, every attempt will be made to immediately contact the persons listed on this form. In the event that I cannot be reached in an emergency, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary. I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed. Coverage by Edgewater Lutheran Church through its accident policy will be used as a backup for what my family’s insurance does not cover. I consent to the use of any video images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of my son/daughter during the activity/event to be used, distributed, or shown as Edgewater Lutheran Church sees fit. I hereby indemnify and hold harmless the above listed parties.
Submit Form
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