Registration Form

Parents Night Out

Sponsored by
Ivy Tech Community College Education Department Students and Faculty

Name: __________________________________________________ Age: _________

Allergies/Special Concerns__________________________________________________
Name: __________________________________________________ Age: _________
Allergies/Special Concerns__________________________________________________
Name: __________________________________________________ Age: _________
Allergies/Special Concerns__________________________________________________
Home Address: ___________________________________________________________
Email Address: ___________________________________________________________
Parent/Guardian Name: ______________________________ Cell Phone: ___________
Parent/Guardian Name: ______________________________ Cell Phone: ___________

Emergency Contact: _______________________________Phone_______________ _______

As parent/legal guardian of above named minors, I understand that Ivy Tech Community
College students and faculty will be supervising my child(ren) while I am attending Muncies
First Thursday events on December 5, 2013. By signing this acknowledgement, I am giving
permission for my child(ren) to participate in all of the activities presented during this event. I
give any guardian or emergency contact listed on this form permission to pick up my child(ren).
I understand that I or the emergency contact listed must be able to be reached via phone
during the entire event. I understand that if my child(ren) are not picked up by 8:15 pm,
authorities will be notified.

Printed Name of Parent/ Legal Guardian

Signature of Parent/ Legal Guardian

I give permission for my child(ren) to be photographed and understand that said photos may
be used for educational and/or marketing purposes with Ivy Tech Community College.

Signature of Parent/Legal Guardian