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FRIDAY NIGHT MOVIE- OCTOBER 25, 2019
16 years and older
6:30 - 9:00 p.m.
CASUAL ATTIRE
BRING A BAG DINNER OR EAT AT HOME- We will serve refreshments!
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COMMUNITY LIFE UNITED METHODIST CHURCH
4115 SOUNDSIDE DRIVE * GULF BREEZE, FL * 32563
FRIDAYDANCECLC@GMAIL.COM
Adult's Name
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Adult's Birthdate (MONTH/DAY/YEAR)
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Adult's Age
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Gender:
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Male
Female
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Adult lives with:
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Both Parents
Mother
Father
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Home address: (street, city, state, zip)
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Home Phone Number
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Email:
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Name, Relationship & Cell Number of person bringing the adult to movie night:
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Under what circumstances would :you like to be notified during the respite event?
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Alternate Emergency Contact; Name, Phone Number:
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What health concerns should we be aware of:
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Does your adult have seizures?
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If yes, what should be done if your adult has a seizure during the dance?
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Please describe any allergies that your adult has, if any. (please include food allergies)
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