Tweens Black History Movie Night
Friday February 26, 2021
Food, Movie Admission, and Transportation Provided
Drop off & Pick Up @ The Gingerbread School 1220 S Houston Ave Humble TX 77338
Movie Trailer- PG 13 Rating- Film Includes Adult Language and Intense Scenes
Name of Participating Tween
Phone Number of Participating Tween (If they have a cell phone)
Parent Contact Number
Parent Email Address
Emergency Contact (Name and Number)
Does Your Tween have any food allergies or restrictive health conditions?
Has your Tween tested positive for Covid 19 or been around someone with Covid 19 Symptoms?
How Did You Hear About The Event?
Next Door App
Word of Mouth
Medical and Liability Release
Medical Release: In the event that I cannot be reached in an emergency during the dates specified on this form, I
hereby give my permission to the physician/hospital by The Gingerbread School , to secure
proper treatment, first aid, and/or order an injection, anesthesia, or surgery for my son or daughter, as deemed necessary.
Liability Release: The activity sponsored by The Gingerbread School is carefully planned and adequately supervised by mature
adults. However, even with the best of planning and precaution, unforeseen events can occur. By signing this form,
the parents or guardian agree to assume and accept all risks and hazards inherent in The Gingerbread School activities. They
also agree not to hold The Gingerbread School or its employees or volunteer assistants liable for damages, losses, or
injuries to the person or property undersigned. The parents or guardians understand that they are signing for the
minor listed on this form and the signature is for both a medical and liability release
I understand that the selected film may contain adult language such as profanity, scenes that may or may not include violence, sensitive subjects about racism and civil rights.
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