Childcare for 1st Annual Date Night

Availble for infants up to 5th Grade!

Parent Information

Parent's Name

Parent's Email

This address will receive a confirmation email

Parent's Cell Phone

Child1 Information

Child1 Name

Child1 Date of Birth

Child Allergies or Special Needs - please explain or type 'None'

Child2 Information

Child2 Name

Child2 Date of Birth

Child2 Allergies or Special Needs

Child3 Information

Child3 Name

Child3 Date of Birth

Child3 Allergies or Special Needs

Payment

Payment 10.00

Initial - In consideration for the benefits to be derived from this activity, I (we) voluntarily waive any claim against Mountainview Community Christian Church, its staff, or volunteers.

Initial - I authorize the group leaders, in whose care the minor has been entrusted, to consent to any x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care to be rendered to the minor under the general or special supervision and on the advise of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether diagnosis or treatment is rendered at the office of physician or said hospital. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical/dental services rendered. This authority is granted only after a reasonable attempt has been made to contact me.

Electronic Signature - Your first and last name

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

Friday, November 8 from 7:00p.m.-8:30p.m.

Childcare for 1st Annual Date Night

Childcare for 1st Annual Date Night

Description

Please Fix the Following