Parents’ Night Out Registration

Parent Information

Parent's Full Name*

Parent's Phone Number*

Parent's Email Address*

Enter Email Confirm Email

Emergency Contact Information

Emergency Contact Name*

If we are not able to reach you at the phone number you provided, who should we contact in the case of an emergency?

Emergency Contact Phone Number*

Child's Information

How Many Children Would You Like to Register?*

First Child's Full Name*

Second Child's Full Name*

Third Child's Full Name*

Fourth Child's Full Name*

Fifth Child's Full Name*

Sixth Child's Full Name*

Seventh Child's Full Name*

Either Child's Full Name*

Do Any of the Children Have Medical Conditions or Allergies That We Need to be Aware Of?*

Yes
No

If yes, please explain in the next question.

Please list any allergies or medical conditions that we need to be aware of.

Be sure to include which child(ren) these apply to.

Permission to Participate*

As parent/guardian of the above named minor(s), I hereby grant permission for my daughter/son to participate in Westside Church of Christ’s Parents’ Night Out event, held at 7300 Stockdale Hwy Bakersfield, California from now until December 31, 2017. I have discussed the event with my daughter/son, and s/he agrees to abide by the rules of the event. I understand my daughter/son will be sent home if s/he is unable to behave within the rules of this event.

I Agree

Medical Authorization*

As the parent / guardian of the above named minor(s), I also grant permission for Ian Nickell, Catie Nickell (RN) or any other adult chaperone with Westside Church of Christ to take whatever steps may be necessary to obtain emergency care as warranted for the well being of my daughter/son. These steps may include but are not limited to the following: - Attempts to contact a parent or guardian - Seek medical examination/treatment for injuries/condition by medical professional. This will be in effect from now until December 31, 2017.

I Agree

Release of Liability*

I agree that all activities are undertaken by the minor at the sole risk of the Minor(s) and myself, and that the Westside Church of Christ, the owners of the Property, and any other adult chaperones shall not be liable for any claims for injuries or damages whatsoever to person or property of the Minor(s) or myself arising out of or connected with the event or arising out of the use of the Property from now until December 31, 2017. I further agree to indemnify and to hold the Westside Church of Christ, the owners of the Property and any other adult chaperone assisting with the event harmless from all claims by or liability to Minor(s) and myself and hereby absolve them from any responsibility for personal injuries and/or property loss arising out of the event. I understand and agree to the policy and terms listed above and agree that any expenses incurred in necessary emergency or other medical treatment will be borne solely by the participant’s medical coverage and/or family.

I Agree

Today's Date*