Parent's Night Out - Parents
Calling stressed out parents! Enjoy a night out with your spouse or just an evening to yourself while we entertain your kids with music, crafts, Christian stories, snacks and more. Child-care is free of charge. Our volunteers have been background-checked and love kids.
Once you have filled out this general information, you will be directed to a second form where you can select the nights for childcare and register your children.
* Emergency Contact 1 - Name and Phone Number
* Emergency Contact 2 - Name and Phone Number
* Insurance information
* Doctor's Information
Release of Liability
- I permit my child(ren) to participate in this event with Peninsula Bible Church Cupertino. I certify my student is able to participate in this event. I understand and fully accept that accidents and injuries are possible. I hereby release and hold harmless Peninsula Bible Church Cupertino, its officers and employees, and designated volunteer group leaders and chaperones, from all liability and from all actions or claims that I or my child now or hereafter have for any damage or injury to my child, or to any person or property, resulting from the negligence or other actions of any employees or agents in connection with my child’s participation in this activity. I understand that photographs, motion pictures, video recordings or other memorializing of this activity and his/her participation therein may occur, and I grant permission to PBCC to use these in media and publications. I and my child waive any right to receive compensation there from.
Permission to Render emergency Aid
- In case of medical emergency, I hereby give permission to the group leader to order medical treatment, including needed tests and x-rays, for my student. Of course, I understand that an attempt will be made to reach me by telephone immediately after any injury and when the diagnosis is completed. I understand that my medical insurance is primary and that I will be responsible for all expenses due to any injuries to my student as a result of participation in this event.
* Sign and date Here - Waiver and Permission to render emergency aid
Add Another Parent/Guardian
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