Fundraiser | Growing in Grace Academy

Parent's Night Out Fundraiser
$25 Donation per Child

Child(ren)'s full name

Child(ren)'s Age(s)

Parent's full name

Phone

Address

Emergency Contacts: to take your child from facility other than Parent (please provide as many people as possible) we will not release a child unless that person is on this form. Let them know photo ID may be required.

AUTHORIZATION FOR EMERGENCY MEDICAL CARE I understand that I will be notified at once in the event of an emergency with my child, and I will make arrangements for medical care of my child with the physician or hospital of my choice. If I cannot be reached to make the necessary arrangements, or in a critical emergency requiring medical care, I authorize Growing In Grace Academy to contact the following:

PHYSICIAN OR CLINIC: Name:

PREFERRED HOSPITAL (with the understanding that all costs associated with a medical transport will be at the family’s responsibility)

LIST ANY MEDICAL FOOD ALLERGIES; please provide an EPI pen if applicable

I, as the parent or legal guardian of the registered, grant permission for the registered to attend the above advertised Parent’s Night Out at Grace City Church as a fundraiser for Growing In Grace Academy. I understand all funds donated will be used for start up costs associated with this new preschool/child care program. (please initial)

I do also release Grace City Church, Growing In Grace Academy, and all volunteer adults from any and all liability or responsibility due to an injury that he/she may incur as a result from participating in any activity at or under the direction of Grace Volunteers.(please initial)

I am fully aware and consent to accept these risks and voluntarily agree to allow his/her participation in activities. If I cannot be consulted in an emergency, I herby give permission to secure treatment with a physician/hospital listed above with the understanding if transport is necessary via ambulance, I am responsible for these costs.(please initial)

I grant permission for photos of my child to be taken without compensation. These photos or videos may be used in websites or for promotion of Growing In Grace Academy. Grace City Church and Growing In Grace Academy will not identify me or my child by name, or release any personal information without additional written permission from me.

We have your Registration for Parent's Night Out, please look for a confirmation email for further instructions by the Director, Angie

Parent's Night Out Fundraiser
$25 Donation per Child

Bourbon Campus

Sundays 10:00am

Owensville Campus

Sundays 10:00am

1912 Nursing Home Road Owensville MO 65066

gracecitychurchmo.gmail.com

(573) 468 - 4004

Leadership:

Parent's Night Out Fundraiser $25 Donation per Child

Bourbon Campus

Sundays 10:00am

Owensville Campus

Sundays 10:00am

1912 Nursing Home Road Owensville MO 65066

gracecitychurchmo.gmail.com

(573) 468 - 4004

Leadership:

Parent's Night Out Fundraiser
$25 Donation per Child