Shady Grove Church - Kids Night Out Registration Form
Proverbs 22:6 Train up a child in the way he should go: and when he is old, he will not depart from it.
Clubber's Name (first and last)
Your answer
Clubber's Address
Your answer
Clubber's Parents/Guardians
Your answer
Clubber Resides with:
Mom's Email
Your answer
Mom's Cell (XXX-XXX-XXXX)
Your answer
Dad's Email
Your answer
Dad's Cell (XXX-XXX-XXXX)
Your answer
Clubber's Date of Birth
MM
/
DD
/
YYYY
Clubber's Grade *
Any Food Allergies? *
Your answer
Does the clubber have any medical issues? *
Your answer
Any activity Clubber should not participate in?
Your answer
Emergency Contact if Dad/Mom are not reachable (name and number) *
Your answer
I understand and acknowledge that my child will be having fun and playing games while at Kids Night Out at Shady Grove Church and that any physical activity can pose a risk of injury. I fully accept the risk and hold harmless Shady Grove Church and any and all persons involved in the Kids Night Out ministry at Shady Grove Church from any legal liability. Confirmed and acknowledged by choosing yes. *
Required
In the event of an emergency that requires the medical treatment of my child, I understand that every effort will be made to contact me or the emergency contact listed. However, if I/we cannot be reached, I give permission to Shady Grove Church and the Kids Night Out volunteers to secure the services of medical professionals to provide any necessary medical care for my child's well being and I assume responsibility for any cost associated with same. Confirmed and acknowledged by choosing yes. *
Required
I give permission for photo(s) of my child to appear among other general Kids Night Out photos by Shady Grove Church.
Kids Night Out registration fees for this year are: $20 for first child, $15 for second child, $10 for third child, with a $50 family maximum. I acknowledge these fees, which are solely utilized for purchase of Clubber materials such as handbook, bags, etc.. *
Required
I have read and accept the above terms and conditions and wish for my child to participate in Kids Night Out at Shady Grove Church. *
Please sign your name electronically to confirm.
Your answer
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