Parents' Night Out

Individual Registration

Please enter information in the form below to process registration for event Parents' Night Out .

First Name *

Last Name

Email *

Cell Phone *

How Many Children? *

We apologize, but our volunteer childcare providers are not trained to watch children with certain special needs. If your child requires special care, please contact Casey Hill at casey@bridgealife.com or 941-705-2337 to discuss accommodations prior to registering.

Child #1 First Name *

Child #1 DoB *

Child #1 Allergies or Concerns *

Child #2 First Name *

Child #2 DoB *

Child #2 Allergies or Concerns *

Child #3 First Name *

Child #3 DoB *

Child #3 Allergies or Concerns *

Child #4 First Name *

Child #4 DoB *

Child #4 Allergies or Concerns *

Child #5 First Name *

Child #5 DoB *

Child #5 Allergies or Concerns *

Child #6 First Name *

Child #6 DoB *

Child #6 Allergies or Concerns *

Child #7 First Name *

Child #7 DoB *

Child #7 Allergies or Concerns *

Child #8 First Name *

Child #8 DoB *

Child #8 Allergies or Concerns *

I/We acknowledge that Bridge a Life is offering Parents' Night Out to my/our family as an expression of care and wrap around support and that Bridge a Life is not being paid or otherwise receiving compensation in exchange for providing care for my/our children. In exchange for this care, I/we agree, on behalf of myself, my children, and my family, to release and forever discharge Bridge a Life, and any of their respective employees, volunteers, and representatives from any and all claims for any accidental injury, death, damages, or other loss of any kind that I, my/our children, or any member of my/our family may suffer or incur arising out of or related to my/our participation in or involvement with the Parents' Night Out or other related Bridge a Life Program. This release of liability includes any accident, injury, death, loss, or damages to my/our child(ren) as well as to other individuals or property which may result from my/our child(ren)’s participation in Parents' Night Out, any actions/omissions of the employees, volunteers, and representatives of Bridge a Life. As the parent, guardian, or authorized representative, I hereby give consent to the Bridge a Life and its employees and volunteers to obtain all emergency medical or dental care for my child(ren). This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of the child(ren) named above. Throughout the event, there may be activities, events, or media releases that could result in my/our child(ren) being photographed. I/we agree that Bridge a Life may use these photographs in promotions for the program, publish them with local articles, or use them to produce videos. If I/we would NOT like my/our child to participate in activities such as these, I/we must notify Bridge a Life, and they will ensure that my/our child is not photographed in the program.

Parents' Night Out Consent *

I have read and agree to the terms above.

Parents' Night Out

Individual Registration

He will cover you with his feathers and under his wings you will find refuge; his faithfulness will be your shield and rampart.– Psalm 91:4

He will cover you with his feathers and under his wings you will find refuge; his faithfulness will be your shield and rampart.
– Psalm 91:4