Name: Parents’ Night Out
Start: 2024-11-16T16:00:00-08:00
End: 2024-11-16T19:00:00-08:00

Parent or Legal Guardian Information

Name*

First Last

Relationship*

Email*

Phone*

Emergency Person (other than above)*

Emergency Person Relationship*

Emergency Person Phone*

What County Do You Live In?*

Have you been to a Help One Child event before?*

Yes
No

How did you find out about this event?*

As a new family, we'd like to contact you to start the process of registering with Help One Child.*

What’s the best way to get in touch with you?

Phone
Email

Kid Information

How many kids would you like to sign up?*

Child #1 Name*

First Last

Child #1 Age*

Child #1 Status*

Foster Child
Adopted
Kinship/Guardianship
Biological

Child #2 Name*

First Last

Child #2 Age*

Child #2 Status*

Foster Child
Adopted
Kinship/Guardianship
Biological

Child #3 Name*

First Last

Child #3 Age*

Child #3 Status*

Foster Child
Adopted
Kinship/Guardianship
Biological

Child #4 Name*

First Last

Child #4 Age*

Child #4 Status*

Foster Child
Adopted
Kinship/Guardianship
Biological

Child #5 Name*

First Last

Child #5 Age*

Child #5 Status*

Foster Child
Adopted
Kinship/Guardianship
Biological

Child #6 Name*

First Last

Child #6 Age*

Child #6 Status*

Foster Child
Adopted
Kinship/Guardianship
Biological

Do any of your kids attending have food/medication sensitivities or allergies?

Yes
No

Please elaborate on the allergies/sensitivities so we know how to best accommodate

Additional Comments:*

HOC Waiver and Release: Permission Form for Minors*

I, the undersigned parent, legal guardian, or foster parent of the above-named Minor(s), hereby give my permission for my child(ren)’s participation in Help One Child’s “Parents Night Out” held at Crosswalk Community Church on November 2024 (the “Event”).

In signing this form, I warrant and represent that I am the parent, legal guardian, or foster parent, that I am 18 years of age or older; and I indemnify and hold harmless, release and discharge Help One Child, the Child and Parent Institute, and Crosswalk Community Church and their constituent organizations, officers, agents, employees, and volunteers from any and all claims for personal injuries, property damage or wrongful death that my child may suffer as a result of his/her participation in the activity described above, whether or not such injuries or damages are caused by the negligence (active or passive) of any of the entities or individuals named or described above.

I agree that in the event my child is injured as a result of his/her participation in the above-named activities, including transportation to and from these activities, recourse for the payment of any hospital, medical, dental, or related costs and expenses will be paid either by me or my spouse, accident, hospital or medical insurance, or any available benefit plan of mine or my spouse.

I consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician, surgeon, or dentist licensed under the Medical Practice Act and Dental Practice Act. As parent, legal guardian, or foster parent, I am responsible for the health care decisions of my child and am authorized to consent to services to be rendered, and law requires no other consent.

I hereby give permission to the physician selected by the Activity supervisory personnel then present to render medical treatment deemed necessary and appropriate by the physician or dentist.

I hereby authorize the making of photographs, motion pictures, videotapes, recordings, or other memorializing of said event and his/her participation therein. In any photos no identifiable features or information (name or face) will be shown.

I agree to the policy.

Signature*