Parent’s Night Out

Child #1 Name *

First Name

Last Name

Child #1 Birthdate

MM

DD

YYYY

Child # 2 name

First Name

Last Name

Child #2 birthdate

MM

DD

YYYY

Child #3 Name

First Name

Last Name

Child #3 birthdate

MM

DD

YYYY

Parent's Name

First Name

Last Name

Parent's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Medical Release: I release Escondido Presbyterian Church (WPC) from all responsibility related to medical issues, illnesses, or injuries that may occur to my child or children listed above during any WPC activities or at any WPC events. The participant/parents/legal guardian accepts personal financial responsibility for any injury or other loss sustained during the activity or event and releases and promises to indemnify, defend, and hold harmless WPC, the WPC staff, volunteers, or other attendees for any illness or injury arising directly or indirectly out of the activities or events. I acknowledge that participation in the activities or events involves risk to the Participant. No matter the injury, I acknowledge and accept the risks of injury associated with participation in the event. I further accept full responsibility for any medical expenses that may be incurred in the event my child needs emergency medical treatment and I promise to indemnify, defend and hold harmless WPC, WPC staff and volunteers, or other attendees for any medical expenses incurred by my child.

Check this box to indicate you agree to the above

Media Release - I hereby give my full consent to Westminster Presbyterian Church (WPC) and its ministries to record (video, photograph, audio, recording or other) my and my children’s participation in any programs or events associated with WPC including WPC Social Media Accounts (Not limited to Instagram, Tik Tok, Facebook, or other). Further, I hereby transfer and assign to WPC the exclusive rights to use and to authorize others to use said images, video, photography, audio recordings or other, for promotional and educational use or resource sale in the future. I understand that my and my child’s image, voice or video recording may be used, but my name or personal information will never be shared publicly without additional, separate consent.

I agree

I do not agree