Better Families Outreach Event Registration

Which event will you attend?(Required)

Parent's Name(Required)

First Last

Phone Number(Required)

Email(Required)

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

County of Residence(Required)

Child(rens) Information(Required)

First Name

Last Name

Date of Birth

Gender

Click on the (+) symbol to add additional children

Consent(Required)

I/We acknowledge that Better Families is offering this Outreach event to my/our family out of a spirit of generosity and compassion and that Better Families is not being paid or otherwise receiving compensation in exchange for providing care for my/our children. For and in exchange for this care, I/We agree, on behalf of myself, my children, and my family, to release and forever discharge Better Families and FlourishNow, Inc., and any of their respective employees, agents, 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 Outreach event or other related Better Families 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 the Outreach event, any actions/omissions of the employees, agents, volunteers, and representatives of FlourishNow, Inc. and/or Better Families. As the parent, domestic partner, or authorized representative, I hereby give consent to the Better Families and/or Flourishnow, Inc. 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 Better Families and/or Flourishnow, Inc. 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 Better Families, and they will ensure that my/our child is not photographed in the program.

I have read and agree to the terms above

Electronic Signature(Required)

Please type your full name

Date of Signature(Required)

20700

239.470.2733

239.470.2733

239.470.2733

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