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Parents Night Out Form 2019
Event Day and Time: December 15th 5:30 to 7:30, dinner will be served 5:30-5:50
Event Address: 9701 North CR 450 West Muncie, IN 47304
Contact us at (765) 749-9654 or dgflynn02@yahoo.com
Childs Name: *
Your answer
Email *
Your answer
Birthday *
Your answer
Age *
Your answer
Age or Grade *
School *
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Address *
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City, State, Zip Code *
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Parents/Guardians *
Your answer
Phone Number *
Your answer
Alternate Phone Number *
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Home Church
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Three words I would use to best describe my child are (outgoing; shy; etc...) *
Your answer
Allergies/ Medical Conditions *
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Adults permitted to pick my child up: *
Your answer
Adults NOT permitted to pick my child up: *
Your answer
Please read the following paragraph and e-sign below.I understand that every measure will be taken by CommUNITY Church to provide for my child's safety and health needs. In the event that medical attention is necessary due to accident or illness, I understand that every effort will be made to contact me. If, however, I cannot be reached, I give my permission via my e-signature to the staff/leadership to secure the services of a licensed medical professional to provide the care necessary, including anesthesia, for my child's wellbeing. I understand that CommUNITY Church will be photographing my child during the Youth meetings. I hereby grant CommUNITY Church permission to use photographs of my child in to promote youth group and/or on their website. Initial Below
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Parent Signature
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