Parents' Night Out: September 2024

First Name

Last Name

Phone Number

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

How many children are you signing up?

Please list the FIRST and LAST names of EACH child you are registering along with their date of birth (MM/DD/YYYY).

Do any of your children have allergies?

Yes

If yes, which child and what allergies?

Is there any other information you'd like us to know regarding your child(ren)?

Dinner Meal

We will be serving pizza for this Parents' Night Out. If your child(ren) require a different meal, you are welcome to bring a sack dinner or eat beforehand.

Consent Questions

Consent to Treat

Medical Treatment Authorization: I understand that I will be notified in the case of a medical emergency. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event that my child is injured or becomes ill. I authorize the adult chaperones to act in my place to consent to all necessary and appropriate x-ray examinations, anesthetic, medical or surgical diagnosis or treatment, and hospital care. I understand that Cornerstone Church will not be responsible for medical expenses incurred solely on the basis of this authorization.

I agree

I have a question

Consent for Photos/Videos

I give permission for Cornerstone Church to take photos and/or videos of my child. I grant full rights to use the images resulting from the photography/video filming, and any reproductions or adaptations of the images, for publicity or other purposes to help achieve the group’s aims. This might include (but is not limited to), the right to use them in their printed and online publicity or social media.

I agree

I DO NOT grant permission

Additional Questions

Is this your first time at Parents' Night Out?

Yes

Do you currently have a church home/a church you attend regularly?

Yes

End of form. Click "submit" to complete registration.

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