Test Gravity 1 Parent Information:Parent's Name:* First Last Parent's Email:* Parent's Phone Number:*Parent's Alternate Phone Number:Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Additional Parent's Name: First Last Event Information:How did you hear about us?Events:*Parent's Night OutEvent Date:* MM slash DD slash YYYY Number of Children for Parent's Night Out:*1 child2 childrenCoupon Code: Total: $0.00 Medical InformationDoes your child have any allergies? Specific dietary needs/food sensitivities? Medical conditions?*Does your 2nd child have any allergies? Specific dietary needs/food sensitivities? Medical conditions?*Registration Policy We regret that we cannot grant refunds for event registrations. If we must cancel an event due to low enrollment, your payment will be refunded. We reserve the right to cancel events and classes due to low enrollment. Registrants will be notified via email if event is cancelled. Children's InformationChild's Name:* First Last Child's Age:*2nd Child's Name:* First Last 2nd Child's Age:*3rd Child's Name:* First Last 3rd Child's Age:*Emergency ContactEmergency Contact: First Last Emergency Contact Relationship to child(ren):Emergency Contact Phone Number:Emergency Contact Phone Alternate Number:In case of emergency, do we have permission to administer CPR and/or authorize an ambulance to transport your child(ren) to a hospital?* yes no Emergency Contact Acknowledgement:* By checking the box, you are agreeing that the information provided for Emergency Contact is accurate. Photo ReleasePhoto Release Permission: I/We give permission for photos/videos to be taken of: Child's Name: First Last 2nd Child's Name: First Last 3rd Child's Name: First Last while he/she is participating in Meridian Learning activities. I/We understand that photos/video may be published online, in printed materials and/or for other promotional purposes, but only to help document student work and illustrate Meridian Learning programs. I/We hereby waive any ownership rights, as well as any right that I/we may have to inspect or approve the finished product in which a photographic or video image may be used including the advertising copy or other matter that may be used in connection therewith or the use to which it may be applied.Agreement:Children's Information, Emergency Contact Information, Photo Release & Registration Policy Acknowledgement:* By signing below, you are agreeing that the Children's Information & Caregiver Information provided is accurate and that you read the Photo Release, Waiver and Studio Rules. Additionally, only in the case of event cancellation by CPCC will fees be refunded. My signature below indicates that I agree to all of the above provisions regarding my family’s and caregiver's participation in the program. Parent/Guardian:* First Last Parent/Guardian Signature:*Additional Parent/Guardian: First Last Additional Parent/Guardian Signature: