Parents’ Night Out

Sponsored by Good Foundations Academy’s PTO

Name and age of Student/siblings:_________________________________________

________________________________________________________________________________________________________________________________

Amount Included: _________ We prefer a check payable to “GFA”

Emergency Contact Information

In the unlikely event we will need to contact you while your child is in our care, please provide emergency contact information:

Home Phone _____________________

Mother’s Cell and Name _____________________

Father’s Cell and Name _____________________

If parents cannot be reached, emergency contact:

Name ______________________ Relation ________________

Phone ______________________ Cell ________________

Physical problems or conditions we should be aware of: ________________________________________________________________________________

Waiver/Release Form

I _______________________________ hereby agree to have my child/children_____________________

_____________________________________________________________________________________participate in the parents night out hosted by GFA’s PTO with the understanding and agreement that I release the Academy from any and all liabilities arising from my child’s participation. I have read and understand the guidelines and conditions of the Waiver/Release Form.

_________________________________________________________

Signature (Parent or Guardian) & Date