Respite Night Signup

Parent/Guardian First Name(Required)

Parent/Guardian Last Name(Required)

Phone(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Respite Night Date

Friday, Nov 8 2024 : 6pm-8pm

Names of child/children (or adults) with special medical, intellectual, or developmental needs who will be attending Respite Night.*

Siblings are welcome! Names of sibling(s) who will be attending Respite Night.

Please share any concerns, allergies or anything else that will help us make this a safe and successful night for your child(ren)

Liability Release- I understand that as a result of participating in this event, my child and/or the participant in my care, will be involved in various activities in and around Millers Creek Baptist Church’s property. I agree to in no way hold Millers Creek Baptist Church, its employees, volunteers, or directors directly or indirectly responsible should an accident, injury, or death occur during or as a result of this event.(Required)

I Agree

Photography Release* I also understand that I and my child and/or the participant in my care may be photographed or recorded in a video format. I give permission for those photographs and/or videos to be used for any lawful purpose including publicity/promotional illustration, advertising and Web content or other use authorized by Millers Creek Baptist Church.(Required)

I Agree

I Decline