Parent Night Out | Family Night In Parent Night Out | Family Night In Saturday, May 11, 2019 | 4:30 - 7:30pm Drop your children off or stay as a family at EPC for a fun themed night! There is no cost to attend, but donations will support local hunger programs in West Linn. How many children are you registering for Parent Night Out | Family Night In?*OneTwoThreeFourFive +Child's Name* First Last Child's Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child's Age:*Child's Current Grade in School:*2nd Child's Name* First Last 2nd Child's Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119202nd Child's Age:*2nd Child's Current Grade in School:*3rd Child's Name* First Last 3rd Child's Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119203rd Child's Age:*3rd Child's Current Grade in School:*4th Child's Name* First Last 4th Child's Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119204th Child's Age:*4th Child's Current Grade in School:*Five + ChildrenPlease list out Name, Date of Birth, Age, and Grade in School for the rest of the children you are registering for.Parent/Guardian Name* First Last Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Address: Best Phone Number to Reach You:*Secondary Phone Number:Home ChurchAllergies / Medical Needs of Child / ChildrenPlease specify which child.In Case of Emergency, Please Contact:*Please include Name, Relationship to Child / Children, and a Phone NumberMedical Authorization:*Your authorization is necessary for participation in EPC Vacation Bible School events. I understand that if I cannot be reached in an emergency, I authorize all medical, surgical, diagnostic and hospital procedures as may be prescribed by the treating physician for my child/children. I also understand that I will be responsible for any medical expenses incurred due to any injury at this event. Yes, I give medical authorization. No, I do not give medical authorization. Person(s) allowed to pick up your child / children each day:*Please include Name, Relationship to Child / children, and a Phone NumberMedia Permission*I give permission to Emmauel Presbyterian Church to use photos of my child/children in whole or in part in promotional materials of the church including church displays, pamphlets, social media, and our website. Yes No Comments or Questions:DonationYes, via PayPalYes, I'll be bringing cash, check, or canned goods.Not at this time.There is no cost to attend our Parent Night Out / Family Night In. However, if you would like to make a donation through PayPal all proceeds will go to support local hunger programs in West Linn. We will also be accepting cash, check, and canned goods at the door.Donation Amount Total $0.00
