Kids will enjoy free pizza and popcorn while watching a movie in the Collide Studio.  Kids can wear their PJ's and bring blankets and pillows. There is no charge for this event.
start
 
Child 1 First Name *

 
Child 1 Last Name *

 
Child 1 Gender *


 
Child 1 Birthdate *

 
Child 1 Allergies

 
Child 1 Special needs

 
Child 1 Additional information

Please provide any additional information we may need concerning your child.
 
Do you have another child to register?

     
 
Child 2 First Name

 
Child 2 Last Name

 
Child 2 Gender


 
Child 2 Birthdate

 
Child 2 Allergies

 
Child 2 Special Needs

 
Child 2 Additional Information

Please provide any additional information we may need concerning your child.
 
Do you have another child to register?

     
 
Child 3 Information

 
Child 3 First Name

 
Child 3 Last Name

 
Child 3 Gender


 
Child 3 Birthdate

 
Child 3 Allergies

 
Child 3 Special Needs

 
Child 3 Additional Information

Please provide any additional information we may need concerning your child.
 
Parent 1 First Name *

 
Parent 1 Last Name *

 
Parent 1 Primary Phone Number (xxx-xxx-xxxx) *

 
Parent 2 First Name

 
Parent 2 Last Name

 
Parent 2 Primary Phone Number (xxx-xxx-xxxx)

 
Emergency Contact Name (other than parent)

 
Emergency Contact Number (other than parent) (xxx-xxx-xxxx)

 
Have you registered a child for VBS this year?

     
 
Insurance Company Name *

 
Insurance Company Phone Number (xxx-xxx-xxxx) *

 
Name of Insured *

 
Insurance Policy Number *

 
Insurance Group Number *

 
Medical Authorization, Release and Agreement
In consideration for the above named Child(ren) being allowed to participate in Kids Night In hosted by Peachtree Corners Baptist Church, Inc. ("PCBC") at 4480 Peachtree Corners Circle, Norcross, GA 30092, I on behalf of myself, my spouse, my Child(ren), my parents, my heirs, assigns, personal representatives, estate, and insurers, agree as follows: I hereby authorize PCBC and its officers, directors, pastors, elders, deacons, representatives, assigns, volunteers, employees, insurers, and all other persons or entities acting in any capacity on their behalf (herein after collectively referred to as the “PCBC Parties” ) to administer first aid, to obtain the services of a licensed physician, and to arrange transportation to a medical facility in case any of the Child(ren) becomes seriously ill, injured or requires immediate medical attention. I hereby grant permission for the PCBC Nurse or trained designate to administer over-the-counter medications, including but not limited to: Tylenol, Ibuprofen, Pseudophed, Claritin, Tums, Benadryl, Anti-Itch Cream, Delsym, Visine eye drops. I authorize any attending physician to render any treatment that they deem necessary for the welfare of the Child(ren). I further understand that my child will be transported in equipment owned, leased, or rented by Peachtree Corners Baptist Church. I assume responsibility for any costs incurred as a result of any such transportation and/or medical services provided to my Child(ren). I certify that the Child(ren) are covered by medical insurance. I HEREBY WAIVE AND RELEASE, AND AGREE TO INDEMNIFY AND HOLD HARMLESS, THE PCBC PARTIES FROM ALL DAMAGES, JUDGMENTS, LOSSES, COSTS, LIABILITIES, EXPENSES, AND ALL OTHER CLAIMS ARISING FROM OR RELATING TO MY CHILD(REN)'S PARTICIPATION IN THE EVENT, WHETHER ARISING IN CONTRACT, TORT, AT LAW, IN EQUITY OR OTHERWISE, EXCEPT THAT SUCH AGREEMENT TO RELEASE, INDEMNIFY AND HOLD HARMLESS SHALL NOT APPLY AS TO ANY INDIVIDUAL PCBC PARTY TO THE EXTENT OF SUCH PCBC PARTY'S GROSS NEGLIGENCE OR INTENTIONAL MISCONDUCT. I further grant PCBC the right to take photographs, videotape, and/or record my Child(ren) and to use their name, face, likeness, voice and appearance and to display same solely for the private use of PCBC. I further certify that I am the parent or legal guardian of the Child(ren) or that I have been granted power of attorney to sign this Agreement on behalf of the parent or legal guardian of the Child(ren). I/We acknowledge that I/we have read and understand all aspects of this document in its entirety. I/We agree that our initials indicated below should be accepted as binding. Both parents’ initials are preferable, but only one parent's initials are required.

 
Please enter your initials to consent to the Medical Authorization, Release and Agreement. *

Thank You!  Your child has been registered for Kids Night In.
again
Powered by Typeform
Powered by Typeform