Parents Night Out: 12/14/18

Date: December 14, 2018

Time: 5:30 P.M. to 9:P.M.

Director: Seana Zilbert (E-Mail: seanazilbert@gmail.com)

Name(required)

Email(required)

Age/Grade Entering in Fall(required)

Male/Female?(required)

Medical Issues/Special Needs/Allergies:(required)

Parent Name:(required)

Address/City/State(required)

Contact Number(required)

Emergency Contact & Number(required)

Medical Release(required)

Medical Release: I give my permission for the Burbank Faith staff to administer basic first aid to my child (named above) in the event of an injury. I understand that the Burbank Faith staff will contact emergency services in the event of a significant injury and all expenses for such emergency services will be paid by me. Photo Release: I hereby grant the above named church permission to copyright and use photographs/videos taken at Burbank Faith of the minor designated above in any manner or form for any purpose lawful at any time. I waive any right that I may have to inspect or approve the finished product or written copy, that may be used in conjunction therewith, or the use to which it may be applied. Permission to Attend: I give permission for my child (named above) to attend the Burbank Faith “Parents Night Out” listed above. I understand that the information I give for this registration will only be used by the Burbank Faith Church, and that all registration information will be removed from the hosting site by December 31 of this year. Parent Signature (Type Name)

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