Parents Night Out Registration Form

PARENTS NIGHT OUT!
NEW DATES ANNOUNCED!

MARCH 28, 2025

APRIL 25, 2025

Gym - Crafts - Movie - Pizza - Snacks - Drinks

Children: 3 years and older

(must be potty trained)

Hours: 6-8:30 pm

__________________________________________________________________________________

Pricing: $40/child

Payment is due when registration is processed and confirmed.

Each child must have a signed policy form on file.

Cancellation Policy: Payment is refunded minus $10 transaction fee for cancellations up until 24 hours prior to event. For cancellations within 24 hours, 50% of payment will be refunded.
Child Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Gender*

MaleFemale
Is there anything we need to know about your child?
2nd Child's Name

First NameLast Name
2nd Child's Date of Birth

MonthDayYear
Date
2nd Child's Age
2nd Child's Gender

MaleFemale
Is there anything we need to know about your second child?
3rd Child's Name

First NameLast Name
3rd Child's Date of Birth

MonthDayYear
Date
3rd Child's Age
3rd Child's Gender

MaleFemale
Is there anything we need to know about your third child?
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship*

Adults Authorized to pick up your child

	First & Last Name
Adult #1
Adult #2
Adult #3
Adult #4

Payment & Confirmation
Please indicate which date(s) you are enrolling:*

March 28, 2025April 25, 2025
If you have any difficulties, please email therapywest2@gmail.com
Cancellation Policy: Payment is refunded minus $10 transaction fee for cancellations up until 24 hours prior to event. For cancellations within 24 hours, 50% of payment will be refunded.

My Products

March 28, 2025$40.00

Number of Kids
Item subtotal:$0.00

April 25, 2025$40.00

Number of Kids
Item subtotal:$0.00

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Parent/guardian Signature*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty: