KIDS NIGHT OUT

PARENT / GUARDIAN INFORMATION

Parent/Guardian Name

This address will receive a confirmation email

Phone

CHILD / CHILDREN INFORMATION

Child's Full Name

Child's Age

Date of Birth

Allergies / Medical Conditions / Special Instructions

#2 Child's Full Name

#2 Child's Age

#2 Child's Date of Birth

Allergies / Medical Conditions / Special Instructions

#3 Child's Full Name

#3 Child's Age

#3 Child's Date of Birth

Allergies / Medical Conditions / Special Instructions

#4 Child's Full Name

#4 Child's Age

#4 Child's Date of Birth

Allergies / Medical Conditions / Special Instructions

#5 Child's Full Name

#5 Child's Age

#5 Child's Date of Birth

Allergies / Medical Conditions / Special Instructions

EMERGENCY CONTACT

Emergency Contact Name

Relationship to Child/Children

Emergency Contact Phone Number

MEDICAL INFORMATION

Primary Doctor Name

Doctor Phone Number

Insurance Provider

Policy / Member ID

PERMISSIONS & WAIVER

Emergency Medical Consent

I authorize Harvest Church staff and volunteers to seek emergency medical treatment for my child if I cannot be reached.

YES

Liability Waiver

I understand that participation in Kids Night Out may include physical activity, games, recreation, and other activities. I release and hold harmless Harvest Church, its staff, volunteers, and representatives from liability for injuries, damages, or losses arising from participation, to the fullest extent permitted by law, except in cases of gross negligence or intentional misconduct.

YES

Photo & Video Permission

I give permission for Harvest Church to use photos/videos of my child for church-related purposes, including social media, promotional materials, and church presentations.

YES NO

Parent / Guardian Agreement

By signing below, I confirm that I am the legal parent/guardian of the child listed above. I certify that the information provided is accurate, and I agree to all terms listed in this form.

Parent / Guardian Digital Signature

DATE

PAYMENT

Pay now with a credit card, or choose the “Cash” option in the drop-down menu to pay the night of the event.

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

KIDS NIGHT OUT

Description

Please Fix the Following