2025 Waiver Form form for Parents Night Out

for children already signed up on our Sign Up Genius for the event.

This waiver is REQUIRED for attendance at Parents Night Out. If you have any issues or questions, please email Mindy Macrone-Wojton at MacRoneWojton.M@gmercyu.edu

Thank you!!!

Registration Waiver Form - Parents’ Night Out 2025

Please fill out a different form for each child attending. You may have to refresh the page after your first form submission.

Thank you!!!

Participant Name

First Name

Last Name

Participant Birth Date

Birth Date

YYYY

Please check one

Participant is NEW to this program

Participant has attended disAbility Ministry events before (i.e. TOPSoccer or Adaptive Sports)

Participant interests? Also, if your child has attended this program before, please share what activities they liked best.

We are providing pizza for participants. Will your child eat pizza, and if so, how many slices do they usually eat?

Special Diet or restrictions?

Please describe

Allergy Alerts

Please list any allergies including food or medications

Sensory/Sensitivity concerns

Please list

History of Seizures?

Yes

Behavior/Safety concerns

Please list and describe. Mindy may reach out to you for more information to best serve your child and the group. Please know that we may require action from parents/guardians for behaviors that affect the safety of other participants.

Other medical information or concerns we may need to know?

Parent/Legal Guardian's Name

First Name

Last Name

Cell Phone Number

(###)

###

####

Guardian Contact Name and Phone number

for any additional phone numbers different than above.

Photo Release

Crossroads Presbyterian Church and Gwynedd Mercy University would like to take pictures of the participants and the activities they are participating in. Do we have your permission to take your child's picture to use in the academic setting, church newsletter, social media and print platforms?

Yes

Parent/Guardian Signature for Photo Release, Liability Release, Medical Treatment Permission, Early Return Home Policy

Please sign by typing your full name in the box below. IT IS THE INTENTION OF GUARDIAN BY THIS AGREEMENT TO EXEMPT AND RELIEVE ORGANIZATION AND ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE, OR WRONGFUL DEATH OF MINOR CAUSED BY ANY ACT OF NEGLIGENCE OF ORGANIZATION AND ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES. For and in consideration of permitting (MINOR) to observe, or use any facility or equipment of Crossroads Presbyterian Church for Parents Night Out, or engage in and/or receive instruction in any activity or activity incidental thereto SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY at: Crossroads Presbyterian Church in the Township of Limerick, County of Montgomery, and State of Pennsylvania, beginning on the day of February 15th, 2025, and through the day April 11, 2025, this waiver will serve Parents' Night Out in this time period listed whether or not the participant attends the activity on one date or more than one date, the undersigned parent and/or guardian of (MINOR): hereby voluntarily and absolutely releases, discharges, waives, and relinquishes any and all loss or damages or actions or causes of action for personal injury, property damage, or wrongful death occurring to (MINOR) as a result of (MINOR)'s observing or using facilities or equipment of ORGANIZATION, or engaging in or receiving instructions in any activities SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY or in activities incidental thereto wherever or however the same may occur, and for whatever period said activities or instructions may continue. The undersigned parent or guardian of MINOR for him/herself, his/her heirs, executors, administrators, or assigns agrees that in the event any claim for personal injury, property damage, or wrongful death shall be prosecuted against ORGANIZATION or its officers, agents, servants, or employees, the undersigned parent or guardian will indemnify and hold harmless ORGANIZATION and its officers, agents, servants, or employees from any and all claims or causes of action by (MINOR) or by any other person or entity, by whomever or wherever made or presented, and under no circumstances will the undersigned parent or guardian of MINOR present any claim against ORGANIZATION and said persons for personal injuries, property damage, wrongful death, or otherwise, caused by any act of negligence by ORGANIZATION and said persons. The undersigned parent or guardian represent that he/she has read this Release, has requested and has been provided with, or has requested and declined advisement on the potential dangers/risks of engaging in the observation, activities, or instruction offered, assumes all risks associated with such dangers and risks, and is fully aware of and understands the terms and the legal consequences of the signing of this Release. The undersigned parent or legal guardian intends his or her signature to be a complete and unconditional release of all liability to the greatest extent allowed by law and if any portion of the Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. Medical Treatment Permission: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical, or dental diagnosis, or treatment hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provision of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization. Early Return Home Policy Should it be necessary for my child or youth to return home due to medical reasons disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

Checkbox

I agree to the Liability Release, Medical Treatment Permission, Early Return Home Policy

Today's Date

YYYY

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