Kid's Night Out Registration Form

Kid's Night Out Registration

Episcopal Church of the Atonement 36 Court St. Westfield, MA 413-562-5461
Saturday, March 22, 5:30-7:30
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
#1 Child's Name/Preferred Name

First NameLast Name
Age
Allergies/Food Sensitivities/other (list below)
Additional Information: (Child's special interests, activities)
#2 Child's Name/Preferred Name

First NameLast Name
Age
Allergies/Food Sensitivities/other (list below)
Additional Information: (Child's special interests, activities)
#3 Child's Name/Preferred Name

First NameLast Name
Age
Allergies/Food Sensitivities/other (list below)
Additional Information: (Child's special interests, activities)
Parent/Guardian Information
Name

First NameLast Name
Home Number
Cell Number (number best to call night of event)
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alternate Emergency Contact's Name

First NameLast Name
Relationship
Alternate Emergency Contact Phone Number
Additional Information/Questions
You may also contact the church office @ 413-562-5461, program@atonementwestfield.org with any questions
To make a Good Will Contribution to help with the costs of Kid's Night Out please click HERE (specify "KNO")
Should be Empty: