Maryville Fun |

PARENTS’ NIGHT OUT!

JUNE 22 5:30-8:30 PM

$45 PER CHILD, SPACE IS LIMITED

CHILDREN AGES 5-12 ONLY

6-22-24 Parents' Night Out Registration Form

Step 1 of 2

Required Details

Parent or Guardian Name(Required)

First Last

Phone Number(Required)

**Please provide a valid cell phone number incase we need to contact you during the event.

Email Address(Required)

Number of children attending(Required)

Please enter a number from 1 to 5.

Name of child #1(Required)

Child #1 date of birth(Required)

Name of child #2(Required)

Child #2 date of birth(Required)

Name of child #3(Required)

Child #3 date of birth(Required)

Name of child #4(Required)

Child #4 date of birth(Required)

Name of child #5(Required)

Child #5 date of birth(Required)

How did you hear about this event?

ASSUMPTION OF RISK, WAIVER OF LIABILITY, MEDIAL AUTHORIZATION AND MEDIA RELEASE

As legal guardian of the child/children above, hereafter, child(ren) I recognize the potential of injuries that can occur during physical activity. Being fully aware of these dangers, I voluntarily consent to and ACCEPT ALL RISKS associated with the participation of the above-mentioned person (s) participating, as well as myself, in all Maryville’s Play Station locations, programs and activities.

In consideration for allowing me and my child(ren) to use these facilities, I, on my behalf of my child(ren) an dour respective heirs, administrators, executors and successors, hereby VOVENANT NOT TO SUE and FOREVER RELEASE Maryville’s Play Station, its officers, directors, employees or agents from all liability for any and all damages or injuries suffered by my child (ren) while under the instruction, supervision, or control of Maryville’s Play Station, including without limitation, those damages or injuries resulting from acts of negligence on the parts of its officers, directors, employees, or agents.

In the event of an emergency, I would like my above- mentioned child (ren) to be taken to a hospital for medial treatment and I hold Maryville’s Play station and its representatives harmless in the execution of this action. Additionally, I hereby agree to individually provide for all possible future medical expenses which may be incurred by me or my child as a result of any injury or illness sustained while participating r Maryville’s Play Station.

In addition, I’m granting Maryville’s Play Station permission for my child to be filmed, videotaped, audiotaped, or photographed by any means and are granting full use of their likeness, voice, and words without compensation.

I have read and understood this ASSUMPTION OF RISK, WAIVER OF LIABILITY, MEDICAL AUTHORIZATION AND MEDIA RELEASE. I VOLUNTARILY affix my name in agreement.

Signature(Required)

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