Clone of Parents Morning Off

Crew x AWOH Movie Night

The below form is required for registration for each child
Child's Information (Please note, you must complete a form for EACH child you wish to register even if siblings!)
Child's Name*
Age:*
Nickname
Signature
What would your child like to drink?*
Please mark any special health needs or disability your child has so we can support them most effectively*

Intellectual or Developmental Disability/DelaySocial/Emotional Challenges/Behavioral DifficultiesNoneAutismADHDOther
Please confirm you recognize this is a drop off event where children must be able to attend without a parent for 2 hours and no 1:1 support*

YesNo
Please provide any additional information that you think is important or may affect your child's information or that we should know about prior to their attendance including information about their support needs (i.e. communication or participation related)!*

Parents/Guardian Contact Information
Parent/Guardian 1*

First NameLast Name
Relationship to Child*
E-mail*
example@example.com
Cell Phone*
Format: (000) 000-0000.
Home Phone*
Format: (000) 000-0000.
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Work/School Phone
Format: (000) 000-0000.
Where would you like to be reached while your child is with is in the event of an emergency*

Cell PhoneWork PhoneHome Phone

Emergency Contacts/Authorized Pickup

Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.
Full Name*

First NameLast Name
Primary Phone Number*
Format: (000) 000-0000.
Relationship to Child*
Where would parent/guardian 2 like to be reached in the event of an emergency?

Cell PhoneWork PhoneHome Phone

Statement of Understanding & Liability Release
A Work of Heart Counseling / Crew Social Group has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported.*
Type first and last name above to consent
Acknowledgement of Hold Harmless: 1. Assumption of Risk I understand that participation in activities hosted by A Work of Heart Counseling/Crew Social Group, including but not limited to the Movie Night event, involves certain inherent risks. These may include, but are not limited to, minor injuries, accidents, or incidents that may occur during the event. I voluntarily assume all risks associated with my child’s participation in this event.2. Release and Hold Harmless Agreement In consideration of my child’s participation in this event, I, on behalf of myself, my child, and our heirs, personal representatives, and assigns, hereby release, waive, discharge, and agree to hold harmless A Work of Heart Counseling, its owners, employees, volunteers, agents, and representatives (collectively, “Released Parties”) from any and all claims, demands, causes of action, or liability of any kind arising out of or related to my child’s participation in the Movie Night event, including any injury, loss, or damage to person or property, whether caused by the negligence of the Released Parties or otherwise. 3. Indemnification I agree to indemnify and hold harmless the Released Parties from and against any and all claims, damages, losses, costs, and expenses (including reasonable attorney’s fees) arising out of or resulting from my child’s participation in the event, including any breach of this agreement.*

YesNo
A Work of Heart Counseling/Crew Social Group will take photographs and/or video footage during the Movie Night event for use in marketing materials, social media, newsletters, website content, and other promotional purposes.*

I grant A Work of Heart Counseling/Crew Social permission to photograph and/or record my child and/or myself during this event and to use such images and footage for promotional and educational purposes without compensation. I understand that I will not be identified by name without my express written consent.I I do NOT grant permission to photograph or record my child and/or myself for any purpose.
Behavioral Expectations: I agree that my child will conduct themselves in a respectful and safe manner during the event. A Work of Heart Counseling/Crew Social Group reserve the right to request a participant be picked up from the event whose behavior poses a risk to the safety or well-being of others, without refund if applicable.*

Yes I understand
Sign Document*
Date Signed*

MonthDayYear
Thank you for participating in this event!

Registation Fee*

Registration Fee - 1 Child

$50.00 Quantity

Enter coupon

Total

$0.00

Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info
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Crew x AWOH Movie Night

Child's Information (Please note, you must complete a form for EACH child you wish to register even if siblings!)

Parents/Guardian Contact Information

Emergency Contacts/Authorized Pickup

Medical / Health Information

Statement of Understanding & Liability Release