Kids' Night Out April 19, 2024

Games, Crafts, Dinner, Friends and Fun for all children ages 2 years old through current 5th graders.

What: Kids Night Out!
Where: Gloria Dei Lutheran Church
When: April 19, 2024
Time: 5:30 pm - 8:30 pm
$35 first child, $5 for each additional child

*This form allows you to register up to 4 children from the same household. If you need to register more than 4 children from the same household, complete the form for the first 4, then complete a second form for additional child(ren), but select 'Pay at the Door' for payment. Questions, please contact us: 605-371-3737

2 year old - current 5th graders eligible to participate.

You MUST bring what is necessary for your child's bathroom needs.

Proceeds support high school students attending the National Youth Gathering July 2024.

Household Information

Please provide information about the adult(s) in the household here.

Name

This address will receive a confirmation email

Please enter cell phone number with area code:
xxx-xxx-xxxx

This number will be used as primary Emergency Contact during KNO.

Phone

Parent/Guardian #2 Name

Parent/Guardian #2 Email

Please enter cell phone number with area code:
xxx-xxx-xxxx

Parent/Guardian #2 Phone

Emergency Contact Information

The parent(s)/guardian(s) listed above will be contacted at the cell phone number(s) provided in the case of emergecy. Please provide an alternate emergency contact.

Emergency Contact name and phone

Permissions

Events may be photographed or videoed for publicity purposes and may be posted on the Gloria Dei website and/or social media platforms. Please contact Gloria Dei to opt out.

I give permission for my child to attend and participate in the above event sponsored by Gloria Dei Lutheran Church. I authorize an adult, in whose care my child has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to my child under the general or special supervision and on the advice of any physician or dentist 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. I shall be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered to my child pursuant to this authorization.

Yes No

I consent to receive communications (which may include a phone, mail, email) from Gloria Dei. I understand I may proactively manage my preferences or opt-out of communications with Gloria Dei at any time by contacting the Church Office.

I agree

Checking this box acknowledges my electronic signature (required).

I agree.

Child 1 Information

First Name

Last Name

Birthdate (mo/da/year)

Allergies?

Yes No

Allergies to: Peanuts Tree nuts Soy Wheat Dairy Eggs

Other allergies

Medical conditions

Does this child have a disability?

Yes No

If yes, please explain the disability.

Child 2 Information

Please note, for child 2, 3, and 4, information is listed as optional. Please complete all information for each child your are registering.

First Name

Last Name

Birthdate (mo/da/year)

Allergies? Yes No

Allergies to: Peanuts Tree nuts Soy Wheat Dairy Eggs

Other allergies

Medical conditions

Does this child have a disability? Yes No

If yes, please explain the disability.

Child 3 Information

First Name

Last Name

Birthdate (mo/da/year)

Allergies? Yes No

Allergies to: Peanuts Tree nuts Soy Wheat Dairy Eggs

Other allergies

Medical conditions

Does this child have a disability? Yes No

If yes, please explain the disability.

Child 4 Information

First Name

Last Name

Birthdate (mo/da/year)

Allergies? Yes No

Allergies to? Peanuts Tree Nuts Soy Wheat Dairy Eggs

Other allergies

Medical Conditions

Does this child have a disability? Yes No

If yes, please explain the disability.

Payment

All payments are non-refundable.

Use the dropdown box below to select the number of children you are registering. If you are paying by check or correct change, you will find that option here as well.

Gloria Dei Lutheran Church respects your privacy.

Unnamed Label

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Kids' Night Out April 19, 2024

Description

Please Fix the Following