Parent’s Night Out

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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 at least 7 days prior to each registered date in order to receive a refund.

$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

Saturday, October 1st

Movie: Zootopia

Saturday, October 15th

Movie: Hotel Transylvania

Saturday, November 5th

Movie: Emperor’s New Groove

Saturday, November 12th

Movie: Beauty and the Beast

Saturday, November 19th

Movie: Free Birds

Saturday, December 10th

Movie: Polar Express

Saturday, December 17th

Movie: Arthur Christmas

Saturday, January 7th

Movie: Finding Dori

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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