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 youth@athleticclubofbend.com 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
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Saturday, October 15th
Movie: Hotel Transylvania
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Saturday, November 5th
Movie: Emperor’s New Groove
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Saturday, November 12th
Movie: Beauty and the Beast
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Saturday, November 19th
Movie: Free Birds
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Saturday, December 10th
Movie: Polar Express
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Saturday, December 17th
Movie: Arthur Christmas
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Saturday, January 7th
Movie: Finding Dori
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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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