Parent Survival Night Registration
Sign up to participate in the parent survival night at Lume Enrichment.
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Child's Full Name
*
First Name
Last Name
Child's Age
*
Does your child have any allergies or medical conditions?
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Child
*
I understand that my child(ren) must be potty independent to participate in Parent Survival Night.
*
I understand
I am the parent or legal guardian of the child(ren) listed on this registration. I authorize my child(ren) to participate in Parent Survival Night at Lume Enrichment and to be supervised by Lume Enrichment staff during this drop-off event.
*
I agree
I understand that participation in children's activities involves inherent risks, including but not limited to falls, collisions, and other injuries that may occur during normal play and program activities. I voluntarily assume these risks on behalf of my child(ren) and release, waive, and hold harmless Lume Enrichment, its owners, employees, volunteers, and representatives from any claims, demands, damages, liabilities, or causes of action arising from participation in this event, except where prohibited by law.
*
I agree
In the event of a medical emergency, I authorize Lume Enrichment to obtain emergency medical treatment for my child(ren) if I cannot be reached.
*
I agree
I agree to be responsible for any damage caused by my child(ren) to Lume Enrichment property or equipment and will cover repair or replacement costs.
*
I agree
I understand that photographs and/or videos may be taken during the event and grant Lume Enrichment permission to use such images for marketing, promotional, and social media purposes without compensation.
*
I agree
I do not agree
Photo's not containing children's faces may be used
Liability Waiver
Photo/Video Consent
My Products
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Parent Survival Night (Child Ages 3-9)
$35.00
$
35.00
Quantity
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Service Fee
$1.50
$
1.50
Credit Card
Register
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