Parents' Night Out

DECEMBER 14, 2018

This event will take place from 6:00pm-9:30pm in Brown Hall at the Church of Reconciliation. Payment of $5.00 per child will be accepted at the door - cash or check only.

A new form must be filled out for each child, even if you have previously attended this event.




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Phone 1

Is Texting Okay? *

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Phone 2

Is Texting Okay?

Would you like to be added to Rec's "Remind" alerts for Children and Family Ministry events, such as Sunday School, VBS, and Parents' Night Out?

Can your child have the snacks and dinner provided?*

Is there anyone aside from the named parents(s)/guardian(s) authorized to pick up your child? *


In signing this, as parent or guardian to the named child, I give him/her permission to attend Parents’ Night out at Church of Reconciliation. I assume responsibility for my child’s behavior and understand that, if my child brings illegal or inappropriate items, including weapons, drugs, alcohol, or tobacco/vape products, or if my child is behaving in a way that is endangering the safety of him/herself or others, I may be contacted to pick my child up immediately.

I understand that Church or Reconciliation and Barrington Neighbors utilize appropriate safety precautions, and that any recreation activity has inherent dangers that no amount of care, caution, instruction, or supervision can completely eliminate. As such, I will not hold the Episcopal Church of Reconciliation and/or Barrington Neighbors or any leaders/sponsors working or volunteering at this event liable for injuries or illnesses that may occur, beyond the limits of insurance carried for such injury or illness. I also give my permission for Church of Reconciliation to seek appropriate emergency medical attention for my child should it become necessary during this event.

I understand that pictures and videos may be taken during this event, and hereby give permission for the use of such pictures and videos of my child for the promotion of future Church of Reconciliation events and/or Barrington Neighbors events.

I understand that pick-up is no later that 9:30pm, and that I will be charged $10 for every 15 minutes past 9:30pm, and that if I am running late for any reason, I must call Jennifer Murphy as soon as possible. I understand that anyone picking up the named child (parent/guardian or authorized pick-up person) may be required to show identification.

I have read and acknowledged the above.