PARENTS NIGHT OUT - YOUTH FUNDRAISER

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REGISTRATION: You may register up to 3 students from the same family on one registration form.  After you submit the registration you will be returned to the GIVE link for our website where you can make your payment via Pushpay. In the dropdown menu, choose Parents Night Out.

FAMILY INFORMATION
Parent or Guardian Name *
Parent or Guardian Name
Emergency Contact Number *
Emergency Contact Number
Address *
Address
Student 1 Information
Name *
Name
STUDENT 2 INFORMATION
Name 2
Name 2
STUDENT 3 INFORMATION
Name 3
Name 3
I give my permission for the above named child to attend Parent Night Out at River Heights Vineyard on August 27, 2016. I release River Heights Vineyard Church, its staff and volunteers, from responsibility and liability for any injury or illness that my child may sustain during this activity. In the event of an emergency, I authorize River Heights Vineyard Church and consent to any emergency medical treatment such as x-ray examination, medical, dental, or surgical diagnosis, treatment and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where services are rendered, either at a doctor’s office or in a hospital. I expect to be contacted as soon as possible. Please put your name in the box below. Your name will represent a legal signature. You will be asked to initial your signature when you drop your children off on August 27.