Parent Date Night Waiver

Please complete this form by filling the information out below or downloading a copy through the link above. Complete the form and provide your payment ($30, cash or check) for the event by Friday, December 20th. Please make checks out to Mansfield Little School. Children ages 2.9-8 are welcome to attend.

Child's Name

Child's Age

Additional Child's Name

Additional Child's Age

Additional Child's Name

Additional Child's Age

Explanation of allergies or other needs

I give permission for my child(ren) to participate in the school-led Parent Date Night on December 20th from 5:30-8:30pm. I understand that parent(s) or guardian(s) assume all risks in connection with the participation of all individuals listed above in this voluntary school sponsored event. In the event that I can not be reached in an emergency, I give permission to call 911 or for staff to contact a medical facility.

Parent Full Name

Signature

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Emergency Contact Name

Emergency Contact Phone Number