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Application for Parents' Night Out
We are excited to learn more about your child! To participate in this program please complete this form for each child in your family who has a developmental disability. Forms are automatically collected by Google Forms.
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Email *
Childs name *
Childs name *
Childs name *
Childs name *
Birth Date *
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Age *
Full Address (Including state, zip, and county) *
Parent/Legal Guardian Name(s) *
Home/Primary Phone *
Cell Phone 1
Cell Phone 2
Email *
Emergency Contact
Who should we call if you cannot be reached?
Name *
Phone *
Relationship to Child *
Medical Contact
Primary Physician *
Phone *
Hospital of Choice *
Medical History
Diagnosis of Developmental Disability *
Allergies (food, medicines, insects, etc) *
Is your child prone to respiratory ailments? *
If so, please describe:
Has your child had seizures in the last two years? *
If yes, when?
Type?
Frequency?
What is the preferred caregiver response?
What cues does your child give when hey or she is getting ill?
Prescription Drugs and Dosages (if not applicable, respond n/a) *
How are medications given (whole, crushed, in fruit, etc)?
Other medical concerns you would like us to know:
Sibling Information
For siblings who might also attend Parents' Night Out
Sibling 1 Name, Birthday, and Age:
Sibling 2 Name, Birthday, and Age:
Sibling 3 Name, Birthday, and Age:
Sibling 4 Name, Birthday, and Age:
Any allergy concerns for siblings?
Any other medical concerns for siblings?
Photo Release
I give permission to the Autism Hope Center to take/use photos of my family during Parents' Night Out for promotional purposes (print materials, newsletters, website, etc) *
Release of Liability
Electronic Signature Consent: I agree that by typing my name as an electronic signature anywhere on this form it is the same as providing a hand-written signature. If I wish to sign by hand I understand that I may print out this form and e-mail, fax, or mail it to the Autism Hope Center. *
I certify that I have answered the above questions truthfully and have not withheld any information relevant to my application. I give consent for my child to participate in the Autism Hope Center Parents' Night Out program at Cascade Hills Church. If my child suffers an injury or illness while participating in this program, and if the volunteers of the Autism Hope Center are unable to contact me at the telephone numbers listed above, I hereby authorize the volunteers of the Autism Hope Center to obtain such emergency medical care or treatment as the medical volunteers of the Autism Hope Center deem necessary. I further consent to the provision to my child of such emergency medical care or treatment, as is deemed reasonably necessary by a licensed physician. This consent is signed for the purpose of authorizing medial treatment under emergency circumstances in my absence.                                                                                                                                                                                                                                                                                                               (By typing your name on the below line you are providing an electronic signature which holds the same weight as a handwritten signature. If you wish to provide a handwritten signature instead you may print out this form and e-mail, fax, or mail this form to the Autism Hope Center.)                                                                                                                                                            Signature of Parent or Legal Guardian: *
I, on behalf of my child, hereby release and waive any and all claims for damages, injury, or death against either the Autism Hope Center and Cascade Hills Church, including their officers, directors, employees, agents, independent contractors, and staff (collectively "Parents' Night Out Releases") that may accrue to me or my child as a result of my child's participation in the Parents' Night Out program, and agree to indemnify, protect, and hold harmless the Parents' Night Out Releases from any claim or liability whatsoever, including, but not limited to, personal injury, property damage, court costs, and attorney's fees, however caused, as a result of my child's participation in the Parents' Night Out program, except for conduct constituting gross negligence by Parents' Night Out Releases.                                                                                                                                                         (By typing your name on the below line you are providing an electronic signature which holds the same weight as a handwritten signature. If you wish to provide a handwritten signature instead you may print out this form and e-mail, fax, or mail this form to the Autism Hope Center.)                                                                                                                                                                                                                            Signature of Parent or Legal Guardian: *
Today's Date *
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COVID Release of Liability
In consideration of my child's participation in the Autism Hope Center Parents' Night Out Program, I acknowledge and agree to the following:                                                                                                                                                                            I am aware of the existence of the risk on my physical appearance to the venue and my child's participation to the activity of the Organization that may cause injury or illness such as, but not limited to, Influenza, MRSA, or COVID-19 that may lead to paralysis or death.                                                                                        (By typing your name on the below line you are providing an electronic signature which holds the same weight as a handwritten signature. If you wish to provide a handwritten signature instead you may print out this form and e-mail, fax, or mail this form to the Autism Hope Center.)                                                                                                                                                                                                                                                                                                       Signature of Parent or Legal Guardian:
In consideration of my child's participation in the Autism Hope Center Parents' Night Out Program, I acknowledge and agree to the following:                                                                                                                                 My child has not experienced symptoms that of fever, fatigue, difficulty in breathing, or dry cough or exhibiting any other symptoms relating to COVID-19 or any communicable disease within the last 14 days. Neither my child, nor any member(s) of my household, traveled by sea or by air, internationally within the past 30 days. Neither my child, nor any member(s) of my household, have been diagnosed to be infected of COVID-19 virus within the last 30 days. I recognize that my child may in any case be at risk of contracting COVID-19                                                                                                                                                                                                       (By typing your name on the below line you are providing an electronic signature which holds the same weight as a handwritten signature. If you wish to provide a handwritten signature instead you may print out this form and e-mail, fax, or mail this form to the Autism Hope Center.)                                                                                                                                                                                                                                                                                                       Signature of Parent or Legal Guardian:
With full knowledge of the risks involved, I hereby release, waive, discharge the Autism Hope Center and Cascade Hills Church, its board, officers, independent contractors, affiliates, employees, representatives, successors, assigns, and from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by my child related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19. I agree to indemnify, defend, and hold harmless the Autism Hope Center and Cascade Hills Church from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19. By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old and fully competent to give my consent; that I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation. This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.                                                                                                                                                       (By typing your name on the below line you are providing an electronic signature which holds the same weight as a handwritten signature. If you wish to provide a handwritten signature instead you may print out this form and e-mail, fax, or mail this form to the Autism Hope Center.)                                                                                                                                                                                                                                                                                                       Signature of Parent or Legal Guardian:
Today's Date
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Autism Hope Center Contact Info
Address: Post Office Box 6028, Columbus, Georgia 31917-6028. Office Phone: 706-604-6333. Fax: 706-617-6406. Facebook: www.facebook.com/AutismHopeCenter . Website: www.autismhopecenter.com . Email: autismhopecenterllp@gmail.com
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