Kids Night Out!

Parent's Name *

First Name

Last Name

Parent's Phone *

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Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

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I hereby solely and expressly assume liability for all risks and waive any claim I might have against Amy J. Sachs, Karen Murray or individuals acting in the capacity as agents of the organization (staff members, independent contractors, volunteers, etc.). I assume full legal liability for my child’s actions on campus and release Amy J Sachs, Karen Murray, and/or agents acting on their behalf from any claims made as a result of my child's actions. This release shall be effective and binding upon the parties, as well as their heirs, beneficiaries, assigns, successors and legal representatives. *

By checking the box, I acknowledge that I have read and understand this release.

Electronic Signature *

By entering your name below, you agree to the conditions set forth in this form.

First Name

Last Name