New Hope Children’s Event Release & Information

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FRIDAY, FEBRUARY 11, 2022 / 6p-11p / Kids Valentine Fun Night (Parents Night Out) held at New Hope Church

Untitled Title

Today's Date *

YYYY

Child's Name (please complete separate form for each child.) *

Address *

Gender *

Male

Female

Grade Level / Age *

Data of Birth *

YYYY

Please list any medical issues, health issues, medicines taken, growth issues, developmental issues, etc. that we need to know that may impact your child while with us. Also, this will help us in making sure your child has a great time at the event with us.

List Name of Person dropping off child *

List Name of Person(s) who may pick up my child after event *

Estimated Drop off time (from 5:45p onward) *

Name(s) and Phone Number(s) of Parents/Guardians *

Name/Relation and Phone Number of 2nd Emergency Contact *

*I understand that the Sponsors of the event will make every attempt to contact me and the 2nd emergency contact with any medical issue, but should I not be able to be reached, I understand that immediate medical care may be needed, and I authorize the Sponsors to seek and provide medical attention including, but not limited to dental, emergency, hospital, ambulance, doctor, etc. if needed during the event. By typing my full name and "Yes" below, I agree to this. *

*I have asked any questions regarding the event’s activities, and I allow my child to participate in the related activities and programs. I understand any and all risks that may occur by participating, and I release and agree to not hold blameless the church or sponsors for illness or injuries. Also, If my child does not follow the rules, I agree to come and pick up my child. Please type full name and word "yes" to agree. *

I have read and agreed that this form has been filled out completely by me, and agree to such by typing my full name and "Yes" in the line below. Please also add the month of the signee's date of birth for confirmation. *

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