Parents' Night Out Registration


Friday, December 13, 2019
6:00 PM - 9:00 PM
(You may pick up your child anytime with a proper ID Security Tag)

For ages 3 months thru 5th Grade
Only Snacks will be provided.

Suggested Donation of $10 per child as the proceeds go for upcoming Missions Trips.

Parent First Name*
Parent Last Name*
Parent Email Address*
Parent Cell Phone*
Alternate Cell Phone
Child #1 Name*
Child #1 Age*
Information we need to best provide for Child #1 (allergies, emotional/social/medical needs):
Child #2 Name
Child #2 Age
Information we need to best provide for Child #2 (allergies, emotional/social/medical needs):
Child #3 Name
Child #3 Age
Information we need to best provide for Child #3 (allergies, emotional/social/medical needs):
Child #4 Name
Child #4 Age
Information we need to best provide for Child #4 (allergies, emotional/social/medical needs):
In consideration of participation in events and activities promoted by Batesville Christian Church, the undersigned (for himself, his personal representatives, heirs, and next of kin) hereby releases Batesville Christian Church and their respective officers, ministers, employees, leaders, and agents (“releasees”) of all liability to the undersigned, whether caused by the negligent act or omission of releasees or otherwise while the undersigned is for any purpose participating in such event or property use. It is fully understood by each of the undersigned that there is some inherent risk associated with any event or property usage. In addition, the undersigned agrees to indemnify and hold harmless the releasees from any loss, liability, damage, or cost they incur due to such participation by the undersigned, and any guests (including minors) whether caused by releasees’ negligence or otherwise, and agrees to assume full responsibility and risk for any bodily injury, death, or property damage from releasees’ negligence or otherwise while the undersigned is participating at this event or property use. MEDICAL RELEASE: I hereby authorize the treatment for myself or the named minor by a qualified and licensed medical doctor in the event of a medical emergency, which in the opinion of the releasees, may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed, while participating in a church program including transportation to and from that program. This authority is granted only after a reasonable attempt has been made to contact the emergency contact person below. I authorize an adult, in whose care my child has been entrusted, to consent to x-ray examination, anesthetic, medical, surgical, or dental diagnosis, including treatment and hospital care, to be rendered to my child under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. INSURANCE RELEASE: I understand that in the event that health coverage is needed, the undersigned parent or guardian shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental service rendered to the aforementioned child pursuant to this authorization. The parent or guardian’s signature also signifies their consent to the release of the medical information/special instructions listed below to be released to Batesville Christian Church’s Ministry staff as needed. PERSONAL BELONGINGS RELEASE: I understand that Batesville Christian Church is not responsible for personal belongings. PHOTOGRAPH RELEASE I give permission for Batesville Christian Church or its partner ministries to use photographs containing my image for informational and/or promotional purposes. In selecting "YES" to this release, the individual acknowledges and represents the following: That he/she (or guardian/personal representative) has read the foregoing Release and Waiver of Liability and Indemnity Agreement; and understands that (s)he is assuming liability and indemnifying as to any minor’s damage or injury. This agreement is for Parents' Night Out on December 13, 2019 by Batesville Christian Church. I understand that all responsible caution will be taken by, those persons in charge to prevent injuries, but neither the leaders (staff) nor Batesville Christian Church will be held responsible in case of an accident. This release is binding upon my heirs, executors and assigns. In the case I am unable to be reached in the event of a medical emergency. I hereby give my consent for my child to be treated for personal injury at the nearest facility available and I will be responsible for all charges incurred.
I accept the agreement of the release terms above: *