Youth Ice Skating 23rd October

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Name of child

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Name of responsible adult

*

Contact email for responsible adult

*

Phone number of responsible adult

*

Address

*

Please let us know what transport you require (please note, we will meet at West Vancouver Ice Rink at 2:30pm).

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Please select all that apply.

I will pick up my child from West Vancouver Ice Rink at 3:45pm. I will pick up my child from Lynn Valley United Church at around 4:15-4:30pm. I would like my child to stay for Eat, Play, Love that evening and will pick them up after or join them there (Lynn Valley United Church)

Does the child have any medical conditions and/or allergies we should be aware of (please specify)?

*

Does the child have any support needs we can help with/should be aware of (please specify if so)?

*

I give permission for my child to go ice skating with Lynn Valley United Church staff.

*

Please select all that apply.

I give permission for photos including my child to be used by the church for promotional material, online newsletters, etc.

*

Please select all that apply.

Yes No

Please pay what you can. The outing is $5.35 (or $2 if your child does not require skate rentals).

($5.35 CAD) ($2.00 CAD) ($0 CAD)

Amount

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

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