A Night to Remember Prom: Student Host Registration

Fill out this form to be a student host for A Night to Remember Prom 2019 on May 5th. We need 100 guys and girls to host Honored Guests of the prom. You will be paired up with a guest and hang with them all night.

It is a super fun time and we are so happy that you are considering helping out!

Note: you must be between the ages of 15 and 22 to serve as a student host for this event!
Host Info

 
 
 
 
 
 
Please select one option.
 
Host Parent Info

If the host is under 18, the rest of this form will need to be filled out by a parent/guardian.
 
 
Release Form

PLEASE READ THROUGH the following HOLD HARMLESS AGREEMENT AND AGREE BY SIGNING THE STATEMENT BELOW. Questions can be directed to anighttorememberprommn@gmail.com
MINOR (>18) RELEASE AND HOLD HARMLESS

Event: A Night to Remember Prom 

Location: STMA Middle School West, MN and STMA High School, MN.

Date: 5/5/2019

 

I,                                      (name), am the parent or legal guardian of (the “Minor”), who desires to participate in various programs, events or activities (hereinafter collectively referred to as the “Activities”) operated or sponsored by WESTBRIDGE COMMUNITY CHURCH (hereinafter referred to as the “Church”) or on the property of the Church. I understand and acknowledge that the Church will not allow the Minor to participate in the Activities without releasing and holding the Church harmless from any liability arising out of my participation in the Activities. I have investigated the risks involved in the Minor’s participation in the Activities and fully understand and assume such risks on his/her behalf. Specifically, I understand and acknowledge that the Minor may suffer or experience, among other things, personal injury or bodily damage, medical disabilities, and loss or theft of personal property. I REQUEST THAT THE CHURCH ALLOW THE MINOR TO PARTICIPATE IN THE ACTIVITIES, AND IN CONSIDERATION THEREOF AGREE HEREBY TO RELEASE AND FOREVER DISCHARGE THE CHURCH, ITS OFFICERS AND DIRECTORS, AND ITS EMPLOYEES, AGENTS, AND ANY PARTIES VOLUNTEERING, FROM ALL ACTIONS, CAUSES OF ACTION, INJURIES, CLAIMS, DAMAGES, COSTS OR EXPENSES OF ANY KIND, INCLUDING ANY NEGLIGENCE OF THE CHURCH, GROWING OUT OF OR RELATED TO THE ACTIVITIES (INCLUDING TRANSPORTATION TO AND FROM THE ACTIVITIES) IN WHICH THE MINOR PARTICIPATES. I UNDERSTAND THAT THIS IS A FULL AND COMPLETE RELEASE OF ALL INJURIES AND DAMAGES, WHICH THE MINOR MAY SUSTAIN AS A RESULT OF THE MINOR’S PARTICIPATION IN THE ACTIVITIES, REGARDLESS OF THE SPECIFIC CAUSE THEREOF. I acknowledge and agree that I have given my consent for the Minor to remain in the custody of the Church’s representatives while participating in the Activities. This agreement is binding on my heirs, successors and personal representatives.

 

PHOTOGRAPH & VIDEO CONSENT AND RELEASE – MINOR

 

In consideration of participating in the above-referenced Activities, I give WESTBRIDGE COMMUNITY CHURCH permission to use the minor’s name, likeness, image, voice, and/or appearance in pictures, photos, video recordings, audiotapes, digital images, and the like (collectively “material”), whenever taken or made for use in multimedia or printed presentations and used for display during services, events, or on WESTBRIDGE COMMUNITY CHURCH’S website, or incorporated in non-commercial or commercial products and services or WESTBRIDGE COMMUNITY CHURCH related products or services. I agree that WESTBRIDGE COMMIUNITY CHURCH have complete ownership of such material including the entire copyright. These uses also include, but are not limited to, CD’s, exhibitions, videotapes, reprints, publications, advertisements, and other promotional, commercial, or educational materials in any medium including the Internet. I acknowledge that I or the Minor will not receive any compensation for the use of such material and hereby release WESTBRIDGE COMMUNITY CHURCH, and its agents and assigns, from any and all claims that arise out of or are in any way connected with such use, including, without limitations, from any liability for violation of rights of privacy, publicity, defamation or any similar right.

 

 2019 MINOR- GENERAL RELEASE AND HOLD HARMLESS


Transportation, Event, Photograph and Video Release, Permission for Medical or Surgical Treatment and Power of Attorney

 

PERMISSION FOR MEDICAL OR SURGICAL TREATMENT AND POWER OF ATTORNEY

In the event the Minor suffers an injury or condition during his/her participation in the Activities, including transportation to and from the Activities, which may endanger his/her life, cause disfigurement, physical impairment or undue discomfort if medical treatment is delayed, and reasonable attempts to contact me or the designated alternate contact person have been unsuccessful, to the extent allowed by local law, I hereby appoint the attending WESTBRIDE COMMUNITY CHURCH Church staff member or agent, as the Minor’s agent to act for them and in my name (in any way I could act in person) to make any and all decisions for the Minor concerning his/her personal care, medical treatment, hospitalization and health care. This power of attorney and delegation of authority shall terminate when; the agent is able to contact the designated alternate contact person or me.


The undersigned agrees to the above sections and this agreement is binding on my heirs, successors and personal representatives.


ADULT (18+) RELEASE AND HOLD HARMLESS

Event: A Night To Remember Prom

Location: STMA Middle School West, MN and STMA High School, MN.

Date: 5/5/2019

I, (the prom participant), desire to participate in various programs, events or activities (hereinafter collectively referred to as the “Activities”) operated or sponsored by WESTBRIDGE COMMUNITY CHURCH (hereinafter referred to as the “Church”). I understand and acknowledge that the Church will not allow me to participate in the Activities without releasing and holding the Church harmless from any liability arising out of my participation in the Activities including transportation to and from the Activities. I have investigated the risks involved in my participation in the Activities and fully understand and assume such risks. Specifically, I understand and acknowledge that I may suffer or experience, among other things, personal injury or bodily damage, medical disabilities, and loss or theft of personal property. I REQUEST THAT THE CHURCH ALLOW THE ME TO PARTICIPATE IN THE ACTIVITIES, AND IN CONSIDERATION THEREOF AGREE HEREBY TO RELEASE AND FOREVER DISCHARGE THE CHURCH, ITS OFFICERS AND DIRECTORS, AND ITS EMPLOYEES, AGENTS, AND ANY PARTIES VOLUNTEERING ON BEHALF OF THE CHURCH, FROM ALL ACTIONS, CAUSES OF ACTION, INJURIES, CLAIMS, DAMAGES, COSTS OR EXPENSES OF ANY KIND, INCLUDING ANY NEGLIGENCE OF THE CHURCH, GROWING OUT OF OR RELATED TO ANY SUCH ACTIVITIES (INCLUDING TRANSPORATION TO AND FROM THE ACTIVITIES) IN WHICH I PARTICIPATE. I UNDERSTAND THAT THIS IS A FULL AND COMPLETE RELEASE OF ALL INJURIES AND DAMAGES, WHICH I MAY SUSTAIN AS A RESULT OF MY PARTICIPATION IN THE ACTIVITIES REGARDLESS OF THE SPECIFIC CAUSETHEREOF.

 

This agreement is binding on my heirs, successors and personal representatives.

  

PHOTOGRAPH & VIDEO CONSENT AND RELEASE – ADULT

 

In consideration of participating in the above referenced Activities, I give WESTBRIDGE COMMUNITY CHURCH permission to use my name, likeness, image, voice, and/or appearance in pictures, photos, video recordings, audiotapes, digital images, and the like (collectively “material”), whenever taken or made for use in multi-media or printed presentations and used for display during services, events, or on WESTBRIDGE COMMUNITY CHURCH’s website, or incorporated in non-commercial or commercial products and services OR WESTBRIDGE COMMUNITY CHURCH related products or services. I agree that WESTBRIDGE COMMUNITY CHURCH has complete ownership of such material including the entire copyright. These uses also include, but are not limited to, CD’s, exhibitions, videotapes, reprints, publications, advertisements, and other promotional, commercial, or educational materials in any medium including the Internet. I acknowledge that I will not receive any compensation for the use of such material and hereby release WESTBRIDGE COMMUNITY CHURCH, and its agents and assigns, from any and all claims that arise out of or are in any way connected with such use, including, without limitation, from any liability for violation of rights of privacy, publicity, defamation or any similar right.

 

2019 ADULT- GENERAL RELEASE AND HOLD HARMLESS

Transportation, Event, Photograph and Video Release, Permission for Medical or Surgical Treatment and Power of Attorney


PERMISSION FOR MEDICAL OR SURGICAL TREATMENT AND POWER OF ATTORNEY


In the event I suffer an injury or condition during my participation in the Activities, including transportation to and from the Activities, which may endanger my life, cause disfigurement, physical impairment or undue discomfort if medical treatment is delayed, and as a result of which I am unable, in the opinion of the attending physician to make an informed decision regarding such treatment, and reasonable attempts to contact my spouse or emergency contact person have been unsuccessful, to the extent allowed by local law, I hereby appoint the attending WESTBRIDGE COMMUNITY CHURCH staff person as my agent to act for me in my name (in any way I could act in person) to make any and all decisions for me concerning my personal care, medical treatment, hospitalization and health care. This power of attorney shall terminate when, in the opinion of my attending physician, I am competent to make informed decisions regarding the need for medical treatment, or when the agent is able to contact my spouse or emergency contact person, whichever occurs first.

 

The undersigned agrees to the above-sections and this agreement is binding on my heirs, successors and personal representatives.

Understand that by signing below, you are confirming that you are 18+ and/or a Parent or Guardian of a Student Host of ANTR Prom. By signing below you're also confirming that a Night to Remember Prom, and its affiliates are removed from any and all liability due to injuries incurred before, during or after the tux fitting party, the dress shop, the prom event for any and all reasons including but not limited to negligence on behalf of A Night To Remember Prom Committee, weather, accidents or driving mishaps. I understand that my signature below constitutes a legal signature confirming that I acknowledge and agree to the above terms of acceptance.
 

Description

Fill out this form to be a student host for A Night to Remember Prom 2019 on May 5th. We need 100 guys and girls to host Honored Guests of the prom. You will be paired up with a guest and hang with them all night.

It is a super fun time and we are so happy that you are considering helping out!

Note: you must be between the ages of 15 and 22 to serve as a student host for this event!