Parent's Night

Parent’s Night Out Children ages 3 to 10 join us for pizza, gym games, crafts, movies and popcorn from 5:00pm to 8:00pm. Pre-registration is required and parents may be off-site with a signed liability waver. Children must be fully potty trained to attend. Cancelations must submitted to [email protected] at least 7 days prior to each registered date in order to receive a refund. Please submit this form at least 24 hrs before the event you wish to attend. We will notify you if the date has filled up. $15 Member/$12 Additional Member sibling $20 Non-member Child’s Name(s):_________________________ Age: _____ _________________________ Age: _____ Parent’s Name(s):_________________________________________ Date: _____________________ Parent’s Signature: _______________________ Email Address: ______________________________ Cell Phone#:__________________ Alternate Phone #_________________ Member #______________ Payment Information due upon registration. Please charge to ACB account #______________ Check #_____________ Cash____ Charge to credit card #___________________________________ EXP. Date: ______________ Name on credit card______________________________________________________ Date & Movie Attendance March 25 th .Trolls April 8 th ..Megamind April 15 th ....HOP April 22 nd ...Moana April 29 th ...Sing May 6 th .Secret Life of Pets May 13 th Cloudy with a Chance of Meatballs 2 May 20 th .Kung Fu Panda 3 Informed consent/participant release Child:_____________________________________________ Age:_____ Date of Birth:____________ Child:_____________________________________________ Age:_____ Date of Birth:____________ Parent Name(s):_________________________________________________ Date: ____________ I, the parent or guardian of the above named participant understands the possibility of injuries resulting from activities sponsored by the Athletic Club of Bend (ACB). I hereby acknowledge and accept all risks and hazards incidental to participation in such activities. I hereby release, absolve, indemnify and hold harmless ACB and its directors, employees and agents from any injury, whether to person or property, of the participant resulting from such activities. In case of personal injury to participant, I hereby waive any and all claims against ACB, its directors, employees and agents. I understand there is no insurance coverage provided by ACB for participant and that such coverage constitutes a responsibility of the participant and/or the undersigned. I hereby release from liability and waive any and all claims against any person who, on behalf of ACB, is involved in the transportation of participant in connection with ACB activities. I hereby consent to emergency medical treatment of participant to assure prompt treatment and prevention of undue delay, and I understand that either a licensed physician or trained emergency care technician may provide such treatment. I agree that ACB may use, produce, disclose and distribute participant’s name and/or likeness and the information included on this registration form by ACB. I acknowledge that I have read, fully understand and accept the above provisions, payment and refund policies and I recognize that ACB is relying on such acceptance in permitting participant to engage in ACB activities. In case of serious illness or accident to above named child/children I hereby grant permission to any qualified physician or medical care center to provide emergency medical treatment for my child. In the event an injury or illness is so severe that immediate medical treatment is necessary ACB will exercise good judgment by calling 911. The parent/guardian will be contacted as soon as possible. Contact Information Mother’s daytime phone #: ________________Mother’s cell phone #: ______________ Father’s daytime phone #: _______________ Father’s cell phone #: ________________ Other emergency contact person: ________________________________ Relationship: ___________ Emergency daytime phone # _____________ Emergency cell phone #: _____________ Who other than a parent or guardian is authorized to pick up your child: ______________ ___________________________________________________________________________________ ___________________________________________________________________________________ Is your child taking any medications? ____ Yes ___No If yes, please list medications: ________________________________________________________________________________________ ________________________________________________________________________________________ Any behavior patterns/concerns: _____________________________________________________________ ________________________________________________________________________________________ Any health or allergies: __________________________________________________________________ _______________________________________________________________________________________ Parent/Guardian Signature: ___________________________________ Date: ___________________ .

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