Parent/Guardian Name *

First Name

Last Name

1st Child's Name *

First Name

Last Name

Does this child have any allergies or medical conditions we should be aware of? *

Yes

No

2nd Child's Name

First Name

Last Name

Does this child have any allergies or medical conditions we should be aware of?

Yes

No

3rd Child's Name

First Name

Last Name

Does this child have any allergies or medical conditions we should be aware of?

Yes

No

4th Child's Name

First Name

Last Name

Does this child have any allergies or medical conditions we should be aware of?

Yes

No

I have read and agree to the release statement listed below *

I hereby give the staff of City Light Church permission to see that my child receives any medical attention he/she may need while participating in Woodbridge Parents' Night Out event. I also release City Light Church and its staff of any liability not caused by their negligence during the above activity. This includes the following: - The power to seek appropriate medical treatment or attention on behalf of the child as may be required by the circumstances, including but not limited to, medical doctor and/or hospital visits. - The power to authorize medical treatment or medical procedures in an emergency situation. In case of emergency, I understand that every effort will be made to contact parents or guardians of minor registrants. However, if parents or guardians cannot be reached, I hereby give City Light Church permission to act on my behalf in seeking and administering medical treatment should it be deemed necessary or advisable for the registrant’s health, safety and/or welfare.

Yes, I agree.