Valentines Day Movie Night- Release and Registration Form

Valentines Day Movie Night Release & Registration Form

This is a FREE event for High School Youth in the Greater San Marcos Area. Space is limited and registration is REQUIRED. Dinner, snacks, and drink will be provided for youth who are in attendance at the event. By completing this registration form you are consenting to participation in event activities. This includes release of media photos that are taken at the event. If at any point a youth does not feel comfortable, they are welcome to step out and inform the Youth Services Director.
General Information

Enjoy a movie, while playing movie bingo and learning about healthy relationships.
Youth Name

First NameLast Name
Youth Email
example@example.com
Youth Phone Number
High School
School Name
Example:
Parent Name

First NameLast Name
Parent Email
example@example.com
Parent Phone Number
Parental Consent
The Undersigned, Being a Parent or Guardian of the above named minor releases the Community Action Inc., of Central Texas and HCWC, its representatives, agents, servants, and employees from liability for any injury to said minor, resulting from any cause whatsoever occurring to said minor at any time while attending any Youth Services related activities, programs and events. Community Action, Inc. of Central Texas is also released of any expenses resulting from the injury.

Your child will have the opportunity to participate in Youth Services activities, programs, and events.

This event is a free community event offered by Community Action Inc., of Central Texas, Youth Services, Core Four Parntership. Students are expected to be respectful of each other and should not participate in any behavior that is harmful to another person. To protect the safety of all students, Community Action, Inc. of Central Texas- Youth Services has a no-tolerance for the following at any event:

1.      Use of violence or possession of weapons

2.      Use of alcohol or drugs

3.   Leaving the building prior to event completion

Parents or guardians of students who violate policies will be notified to pick up their child.

During the activity, program, or event, we will be taking pictures of youth that may be used for marketing materials for Community Action Inc., of Central Texas. Please let the Youth Services Director if your childed should be excluded from photos.
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

Valentines Day Movie Night Release & Registration Form

General Information

Parental Consent