2011 Parents Night Out Registration Form
Age _________ Grade __________________
Street Address _________________________________________
City _______________________ State ______ Zip ___________
Home email address _____________________________________
Date of Birth ___________________
Home Church __________________________________________
If none, may we contact you with all that PGPC has to offer? Yes No
Will someone else pick up your child? Yes No
If so, who? ____________________________ Relationship____________
Have you filled out your Emergency Medical Form? Yes No
If not, please print form, complete and bring with you (extras will be available)
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EMERGENCY MEDICAL AUTHORIZATION FORM
Courtesy medids.com and AUMC (PGPC has altered to fit the need of our events)
I, ____________________________________________________________________________
Parent/Guardian of _______________________________________ Born on ________________
do hereby give my consent to PLEASANT GROVE PRESBYTERIAN CHURCH to secure and authorize such emergency medical treatment as the above name requires while under the supervision of said care provider. I also agree to pay all the costs and fees contingent on emergency medical care or treatment for this person as secured or authorized under this consent.
NOTE: Every effort will be made to notify the parents/guardian, etc. in case of emergency. In the event of an emergency, it would be necessary to have the following information (see back for allergies, etc.):
Parent cell phone number: ______________ Home number: ___________________
Physician’s Name: __________________________ Phone number:________________________
Preferred Hospital: ______________________________________________________________
Address: ______________________________________________________________________
Insurance Company: ____________________________ Policy #: _________________________
Name of Insured: ________________________________
If the parents/guardian is unavailable, other relatives or persons to contact in emergency:
Name: ________________________________________
Address: ______________________________________
Phone: _______________________________________
Relationship: ___________________________________
Signature: ________________________________________________
Date: ________________
The safety of your children is of our utmost concern. Thank you again for sharing your children with us.
ADDITIONAL INFORMATION
Please list for us any allergies that we need to be aware of. Please know that if allergies are severe enough to require the need of a life saving EpiPen, you may be asked to volunteer so that you are onsite in case of a true emergency.
___________________________________________________________________________________
Are there any other conditions that we should be aware of? YES NO
If yes, please explain:
_____________________________________________________________________________________________
Thank you in advance for helping us to keep your children safe during this event.
