Parents&#039; Night Out

Family Information

Family Last Name REQUIRED Please fill out this field. Please enter valid data.

Parent/Guardian Information

Parent #1 Name REQUIRED Please fill out this field. Please enter valid data.
Parent #1 Email REQUIRED Please fill out this field. Please enter an email address.
Parent #1 Cell REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Parent #2 Name Please enter valid data.
Parent #2 Email Please enter an email address.
Parent#2 Cell Maximum 20 characters Please enter a phone number.
Street Address of Child(ren)'s Residence REQUIRED Please fill out this field. Please enter valid data.
City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Emergency Contact Information

This person will be contacted if neither parent/guardian cannot be reached.
First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Contact First Name REQUIRED Please fill out this field. Please enter valid data.
Contact Last Name REQUIRED Please fill out this field. Please enter valid data.

Child Information

Child #1

Child #2

Child #3

Child #4

Parent/Guardian Consent

I am the parent/guardian of the above listed children. REQUIRED Yes Please fill out this field.
I grant permission for my child(ren) listed on this form to participate in this event. REQUIRED Yes Please fill out this field.
This event will take place under the guidance and direction of parish employees and/or volunteers from Saint Elizabeth Ann Seton Catholic Church.
- As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor(s).
- I hereby warrant that to the best of my knowledge, my child(ren) is in good health, and I assume all responsibility for the health of my child(ren).
- I agree on behalf of myself, my child(ren) named herein, or our heirs, successors, and assigns, to hold harmless and defend Saint Elizabeth Ann Seton Catholic Church its officers, directors, employees, and agents, and the Diocese of Fort Wayne-South Bend, its employees and agents, chaperones, or representatives associated with the event, from any claim arising from or in connection with my child(ren) attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish, its officers, directors, and agents, and the Diocese of Fort Wayne-South Bend, its employees and agents and chaperones, or representatives associated with the event for reasonable attorney's fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/diocese.

I agree to the above statements. REQUIRED I agree Please fill out this field.

Parent/Guardian Signature
By typing my name below I am the parent or legal guardian of the child(ren) listed on this form and certify that all the above information is correct.

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Date REQUIRED

MM/DD/YYYY

Please fill out this field. Please enter a date.

St. Elizabeth Ann Seton

Catholic Church

Parents' Night Out

Upcoming event