Mom's Night Out RSVP - Partner Additions Do you have a child with a physical or developmental disability?* Yes No Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Email* Phone Number*Format: (xxx) xxx-xxxxPlease list your child's specific diagnosis.*Which organization(s) are you affiliated with? (hold the Ctrl button to select multiple organzations)*Barren HeightsCritically LovedDown Syndrome of LouisvilleFEAT of LouisvilleOtherFood Restrictions (if any)*How would you like to connect?We want to help you connect with other moms who are on similar journeys or have similar interests. In 6 words or less, give us an idea of how you may want to connect with someone new. Example: hiking, autism, faith, adult disabled child. This is completely optional, and your description will be printed on your name tag to allow moms to quickly identify connections.*OPTIONAL* I would like to connect with moms can relate to... (up to six words)Want to receive emails about future retreats, community events, and Barren Heights updates? Yes! All application information is kept confidential. Application information may be shared with event volunteers to better equip them to serve participants. Hold Harmless Agreement By checking the boxes below and submitting this registration form, you are agreeing to an electronic signature which will act as the legal equivalent of your (the applicant's) manual/handwritten signature on this Hold Harmless Agreement.Please check if you agree with the following statements:* I give my consent that the information given at registration may be communicated with Mom’s Night Out leaders and volunteers for the purpose of being equipped to provide me with the best care and assistance. I give my consent that photographs, interviews, and audio/visual recordings during Mom’s Night Out may be used by Barren Heights, Critically Loved, Down Syndrome of Louisville, and FEAT of Louisville (henceforth referred to as “MNO sponsoring organizations”) for training, promotion, and fundraising. I release all MNO sponsoring organizations, their directors, volunteers, and the event host facility from all actions, damages, or personal injuries which may occur to me. I understand that in the event of a minor injury, I may receive first aid treatment. In the event of an emergency, injury, or illness, emergency medical services and I will decide the best course of action. If I am unable to respond to leaders or emergency medical services, I authorize them to take whatever action is necessary for my safety and health. I understand that for everyone to experience a sense of calm, peaceful relaxation, Mom’s Night Out and its hosting venue is an alcohol, drug, and smoke-free environment. Use of cell phones is discouraged except when necessary. By checking this and the above statements and submitting this registration form, I hereby agree to this hold harmless form and all its contents. I waive on behalf of myself, my heirs, and any personal representatives all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss. I understand that this release discharges all MNO sponsoring organizations and the event host facility from any liability or claim that I, my heirs, or any personal representatives may have against them with respect to any bodily injury, illness, death, negligence, medical treatment, or property damage that may arise from, or in connection to any services rendered. This liability waiver and release extends to all MNO sponsoring organizations together with all owners, partners, volunteers, and employees. CAPTCHA Δ
