8Th Grade Middle School Dance/Social

1st ANNUAL

BLACK LITE NITE!

8TH GRADE MIDDLE SCHOOL DANCE/SOCIAL

Sponsored by: Loudoun Do Something Now!, Cardinal Bank, and Aeropostale

Event: Saturday, April 21, 2012—8:00pm-10:30pm

Location: The Carver Center, Purcellville, VA---$5 entrance fee

(Tickets to be sold at each school during the week of 4/16-4/20)

Name of student attending dance: (please fill out one form per child)______

Are you a BRMS or Harmony MS student? (circle one)

What grade are you currently in?______

Parent/Guardian home & cell phone: (home)______(cell)______

Rules and Commitment

*All students participating in dance/social, are expected to exhibit appropriate behavior.

*Please dress casually, but properly.

*In the event of inappropriate behavior, all chaperones will have the right to contact student’s parents, and ask the student to leave, if necessary. In this case, a chaperone will be asked to wait with student until parent or guardian arrives, and there will be no refund given.

*All student participants MUST either be a current student of Harmony MS or Blue Ridge MS with no exceptions.

*If a student leaves this event, they may not re-enter.

*Please arrive NO LATER than 10:30pm to pick up your student.

*Drugs, alcohol or tobacco will constitute a phone call to both parents and local police.

*If student is riding home with another parent, the driving parent must speak directly to a representative of Loudoun Do Something Now (LDSN), to allow this to occur. No exceptions.

*At 10:30pm, there will be chaperones assigned to the outside front doors of the Carver Center, to make sure each student has been picked up.

*This is NOT a Loudoun County Public School (LCPS) event. This event is completely offered by Loudoun Do Something Now (LDSN), a teen volunteer group, to engage our local middle schoolers in safe, fun activities. The chaperones, (high school members of LDSN, college students and adults), will be present for the duration of the event.

* By signing this Waiver, I assume any risk, and take full responsibility and waive any claims of personal injury, death or damage to personal property associated with Black Lite Night dance/social activities and events organized or supported by Loudoun Do Something Now, the Carver Center, Loudoun County Parks and Recreation, Cardinal Bank and Aeropostale. I understand and confirm that by signing this WAIVER AND RELEASE I have given up all future legal rights. I have signed this Agreement freely, voluntarily, under no duress. My signature is proof of my intention to execute a complete and unconditional WAIVER AND RELEASE of all liability to the full extent of the law.

Parents/guardians & students must read, understand and sign form

Parent/Guardian signature:______Print :______

Student’s signature:______Print: ______

To buy a ticket, you MUST have this form completely filled out and turn in with payment.

For more information, please contact LDSN parent advisors, Lisa Adams 540/222-7919 or

Carolyn Sheerin at 540-338-8037.