Parent's Night Out Registration

Parent's Night Out

Fill out this form and pay the fee to hold your spot. Ages 3 (potty trained) to 11. Time: 6:00 - 10:00 pm. There must be a minimum number of children enrolled in PNO. Refunds will be granted should we have to cancel.
Parent's Name *

First Name Last Name
Parent's Phone Number *

Area Code Phone Number
Parent's email address *
example@example.com
Child (1) Name: *

First Name Last Name
Child (1) Age *
Ages 3 (must be potty trained) to 11 years old.
Gender: *

Male Female
Please list any allergies or special needs for Child (1) *
Child (2) Name

First Name Last Name
Child (2) Age
Ages 3 (must be potty trained) to 11 years old.
Gender:

Male Female
Please list any allergies or special needs for Child (2) *
Child (3) Name

First Name Last Name
Child (3) Age
Ages 3 (must be potty trained) to 11 years old.
Gender:

Male Female
Please list any allergies or special needs for Child (3) *
Emergency Contact (1)

First Name Last Name
Emergency Contact (1) Phone Number

Area Code Phone Number
Emergency Contact (2)

First Name Last Name
Emergency Contact (2) Phone Number

Area Code Phone Number
Parent's Night Out hours are from 6:00pm-10:00pm. There will be a $10 late pick up fee imposed for the first 10 minutes (per child) and then an additional $1 per minute thereafter. All late pick up fees must be paid, in cash, at time of arrival. Please contact office if you, or your child's authorized pick up with be late. *
You must provide an authorized contact person in case of emergency, or if we are unable to reach you for some reason, including the necessary pick up of a child. All parties authorized to pick up will be required to provide photo ID before any child(ren) will be released to their care. *
Kids In Action's #1 priority is the safety of the children in our care. We reserve the right to refuse release of children to a parent or authorized pick up believed to be under the influence. If we believe a child's well-being to be in danger we will ask that you contact a designated driver or, we will call a ride share service. We also reserve the right to call authorities if we feel it necessary. *
Kids In Action Policy Agreement: Kids in Action reserves the right to terminate any child from Parent’s Night Out per Kids in Action Policy Agreement which include, but are not limited to:

Children

1. Bullying

2. Defacing and/or destroying center property or property of others

3. Engaging in aggressive behavior toward other children/staff members.

4. Being rude or discourteous to any staff member.

5. Using foul language

6. Stealing from the center, staff, or other children

7. refusing to stay with assigned group.

Parent:

1. Engaging in aggressive behavior toward a child and/or staff member of the center

2. Failure to follow check in/out procedures

3. Using foul language on the premises

4. Being rude and/or discourteous to any staff member

5. Excessive tardiness upon pick up.

6. Being under the influence of drugs or alcohol when picking up child
By signing (typing your legal name) in the space below, you are certifying that all information is correct and that you have read and agree to all provisions listed above.
E-Signature: *

My Products

Parent's Night Out $ 40.00

Child 1

Child 2 $ 15.00

2nd child

Child 3 $ 15.00

3rd Child

Total $ 0.00

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