Fast Food Progressive Dinner

Preteens (4th-6th Grade) are invited as we travel along to fast food restraunts to eat our dinner.

Cost for the event is $20 and covers drink, entree, side, and dessert.

For questions, please contact the church office at 317-856-3766, or email tanyahenthorn@valleymillscc.org.

Child's name & grade:

Parent/Grandparent 1 name:

Email of person registering:

This address will receive a confirmation email

Mobile Phone of person registering:

Address of person registering:

I, the undersigned parent or guardian of the above noted minor(s), do hereby authorize adult workers with Valley Mills Christian Church to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. Further, as a parent or guardian of the minor(s) named above, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold blameless any physician, hospital, or other medical center for regarding such services. My electronic signature confirms that I hereby give witness to the proper completion of this form by the minor's parent or guardian.

TRANSPORTATION WAIVER AND RELEASE: I, the undersigned, give my consent for the person identified above to be transported by Valley Mills Christian Church's employees and volunteers and will assume all liability for their participation in this activity/event and any injury that may result during the transport or at the event/activity. Further, by signing below: 1. I will not hold Valley Mills Christian Church, its employees or volunteers responsible or liable for injury occurring to the named person in the course of such activities or such travel. 2. I hereby accept financial responsibility for personal items lost by the person identified herein. 3. I accept full responsibility and hereby grant permission for my minor child to travel with Valley Mills Christian Church.

PHOTO RELEASE: I understand that photos and video of each event may be taken to further promote future activities for Valley Mills Christian Church. By signing your electronic signature below you grant permission for the image, photo, video, or likeness of those named to be used by Valley Mills Christian Church and posted on the church website or other social media accounts.

Payment $20

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

Sunday, April 12 from 6-8 PM

Preteen (4th-6th Grade) Fast Food Progressive Dinner

Fast Food Progressive Dinner

Description

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