Kinship Support Services Program Event Registration

Parents Night Out!

We're excited to invite you to our exclusive Parent's Night Out event! Leave the kids with Epicenter Staff for a fun-filled evening while you enjoy a well-deserved break!
Ages 4-12. Must be potty trained to participate. Assorted activities including: Play structures, sky zone trampolines, lazer tag, etc., assorted group games, arts and crafts, board games, movie, dinner, and more!
Spots are limited. Waitlisted families will get priority for the next event!

Estamos emocionados de invitarte a nuestro evento exclusivo de Noche de Padres! Deje a los ninos con el personal de Epicenter para una velada llena de diversion mientras disfrutas de un descanso bien merecido!
Edades: 4-12 *Necesitan estar entrenados para ir al baño* Actividades Incluidas:Estructuras de Juego, Trampolines de zona del cielo, Etiqueta Laser, etc. Juegos Variados:Artes y Manualidades, Juegos de Mesa,Peliculas, Cena, y Mas!
Los espacios estan limitados. Las familias en lista de espera tendran prioridad para el proximo evento!

When/Cuando:
Saturday, December 9th 2023

Time/Hora:
5:30pm - 9:30pm

Where/Donde:
Poppy Bank Epicenter Sports and Entertainment 3215 Coffey Ln Santa Rosa, Ca 95403

Family Information
Caregiver Name * Required
First Last
Caregiver Email Address * Required
Caregiver Phone Number * Required
Child Name * Required
First Last
Childs Date of Birth * Required
MM slash DD slash YYYY
Additional Child Name
First Last
Childs Date of Birth
MM slash DD slash YYYY
Additional Child Name
First Last
Childs Date of Birth
MM slash DD slash YYYY
If there are more than three children attending, please list first and last name, and date of birth for each additional child here.
ADDITIONAL TERMS
Please note we are required to have all event participants acknowledge the following:
MEDIA RELEASE * Required
Permission is hereby given to WAYFINDER FAMILY SERVICES® to use audio, video recordings, photographic and electronically created images of the participant noted in this form for public view, including publications, websites or social media sites. Usage of any images or audio is without compensation to said person or to the undersigned on his/her behalf, or individuality. On occasion, specific individuals are identified for profile stories used in grant applications and reports, publications, websites or social media sites. Permission is hereby given to WAYFINDER FAMILY SERVICES® to publish this individual’s story in grant applications and reports, publications, websites or social media sites, with related quotes, after verbal and/or written approval of that story has been granted by said person or by the undersigned on his/her behalf or individuality.
- I have read the Media Release and am in agreement with its contents.
- I would prefer for my child/family NOT to be recognizably photographed or filmed.
COVID Information * Required
While participating in events held or sponsored by Wayfinder Family Services, consistent with CDC guidelines, participants are encouraged to practice hand hygiene, “social distancing” and wear face coverings to reduce the risks of exposure to COVID-19. Because COVID-19 is known to be contagious and is spread mainly from person-to-person contact, Wayfinder Family Services has put in place preventative measures to reduce the spread of COVID-19. However, Wayfinder Family Services cannot guarantee that its participants, volunteers, partners, or others in attendance will not encounter COVID-19.
- I acknowledge that my participation (or my child’s) in Wayfinder Family Services program is at my own risk.
FAMILY PARTICIPATION WAIVER * Required
In consideration of the acceptance of my family’s participation in the activity listed on this form, I, the undersigned, intending to be legally bound, do hereby for myself and my family (including heirs, executors, administrators and assigns) forever waive, release and discharge any and all rights, claims and actions for damages that we may have, or that may hereafter accrue to us against WAYFINDER FAMILY SERVICES, including all of its officers, directors, members and volunteers. I attest and verify that we are physically able to participate in this activity. We further understand that accidents and injuries can arise out of the event; knowing the risks, nevertheless, I hereby agree to ASSUME ALL RISKS OF PERSONAL INJURY, PERMANENT, TEMPORARY, TOTAL OR PARTIAL DISABILITLY, DISFIGUREMENT, PARALYSIS AND ANY OTHER LOSSES OR DAMAGE TO PERSON OR PROPERTY OR DEATH, sustained while participating in, attending, preparing for or traveling to and from the above described activity, including the risk of negligence of the WAYFINDER FAMILY SERVICES, or hidden, latent or obvious defects in the facilities or equipment used.
- I have read this waiver and am in agreement with its contents.
HOLD HARMLESS * Required
In consideration of the acceptance of my family’s participation in the activity listed on this form, I, on behalf of myself and my family, agree if any claim for personal injury or wrongful death is commenced against WAYFINDER FAMILY SERVICES (including its officers, directors, members and/or volunteers), we will defend indemnify and hold harmless WAYFINDER FAMILY SERVICES, from any and all claims or causes of action for personal injuries, property damage or wrongful death that hereafter accrue, arise out of, result from, or are caused directly or indirectly by my family’s participation in this activity.
- I have read the Hold Harmless Release and am in agreement with its contents.
Electronic Signature (please print your full name) * Required

Program Areas

Parents Night Out!

Family Information

ADDITIONAL TERMS