LIBRARY

PARENTAL CONSENT FORM

For: Game Night Lock-In

8 PM August 2nd – 8 AM August 3rd

The Game Night Lock-In at the Library will be held on August 2nd, 2013 at 8 PM through 8 AM on August 3rd. The event will consist of gaming on both the XBox 360 and the computer. Parents should be aware that some of the games are rated M for Mature due to fantasy violence and/or blood. However, also be aware that we strive to keep a friendly and enjoyable environment during our library events. Parents should use their discretion in determining whether or not to allow their children to attend.

All children below the age of 18 must submit this completed and signed consent form to the library prior to the event on August 2nd, or present the form at the door at the event. No one under the age of 18 shall be permitted to attend the event without a completed and signed consent form. Furthermore, we will be enforcing a strict age limit of 12 years old; no one younger than 12 will be permitted to stay at the library overnight.

Library staff will lock the doors at 10 PM, after which no one shall be permitted to enter the building without having made special arrangements prior to the event. Special arrangements must be submitted in written form before the event begins at 8 PM. Furthermore, after the doors are locked, no child under 18 shall be permitted to leave the library without a parent arriving to pick them up. Parents must provide identification to library staff in order to remove their child from the event after the doors are locked. The doors will be unlocked at 7 AM, at which point the children are free to return home on their own or be picked up by parents.

Snacks and drinks will be provided.

Name of Child: ____________________________________________________

Child’s Birthdate: ____/____/____

By filling out this form and signing on the indicated line below, you do hereby grant permission for the above child to attend the Game Night Lock-In at the library. You also recognize that in the event that your child becomes disruptive or is otherwise unable to remain at the library for the entirety of the night, library staff may contact you and request that you bring the child home. Please keep your phone nearby in the case of this occurrence.

Please note that only persons listed below and carrying a valid photo ID will be allowed to pick your child up from the library

Parent’s Name: ___________________________________________________

Parent’s Signature: ________________________________________________

Phone Number: ____________________________

Date: ____/____/____

Emergency Contact #1:                                                                                                   Phone Number:          _____________   

Emergency Contact #2:                                                                                                   Phone Number: _______________  _

Please list on the back of this form any allergies or special needs your child may have during their stay at the library: