PATRIOTS NIGHT OUT Emergency Contact/ Release Form 04/17/2015 1.) Child's Name_____________________________ Grade/ Age_______________ $15.00 Paid___________ Date of Birth_____/_____/______ 2.) Child's Name_____________________________ Grade/ Age_______________ $10.00 Paid___________ Date of Birth_____/_____/______ 3.) Child's Name_____________________________ Grade/ Age_______________ $10.00 Paid___________ Date of Birth_____/_____/______ Make Checks Payable to: Bernard PTO Total__________ *Please include payment to reserve your child(ren)’s place FORMS AND PAYMENT MUST BE RECEIVED BY 4/15/2015 TO ENSURE REGISTRATION IF YOU HAVE ANY QUESTIONS, CONTACT FRANCHESCA GINDLER 314-229-9802 OR FEPG_2001@YAHOO.COM PARENTAL RELEASE/CONSENT/INFORMATION Parent(s) Name___________________________________________ Home Phone #_________________ Address_________________________________________________ Cell # ________________________ Name & Phone # of an Emergency Contact( in case you cannot be reached): ______________________________________________________________________________________ * Please list the names of anyone you would like us to release your child to. Food Allergies or special needs:_______________________________________________________________ I, ______________________________________, parent or guardian of above listed child(ren), hereby give my consent for said children to participate in Patriots Night Out at Bernard Middle School on April 17, 2015 from 6:30- 9:30. I may drop my child off at 6:15 and I will return by 9:30 to retrieve my child. I confirm that participation is voluntary. I also agree to indemnify and hold harmless Bernard Middle School PTO, Bernard Middle School, Mehlville School District, its organizers and volunteers from all claims of injury to persons or property, knowing that every effort will be made to insure the child(rens) safety. I am aware that my child will not be allowed to use their electronic devices while at Patriots Night Out. All devices will be secured by 6:30 and will be returned to the students at 9:15. If I am not comfortable with this, I have the option of keeping all devices at home. I am aware my child will have access to G/PG rated movies and video games that are rate E for everyone. This event is designed for children to engage in safe, fun, and entertaining planned activities. I understand my child(ren) may be required to leave if they endanger others, themselves or act unsuitably for the evening's events. Signature of Parent_______________________________________________ Date_______________