Parent's Night Out Registration SPR

Parent's Night Out

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

First NameLast Name
Parent's Phone Number

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

First NameLast Name
Child (1) Age
Age
Gender:
Please list any allergies or special needs for Child (1)
Child (2) Name

First NameLast Name
Child (2) Age
Age
Gender:
Please list any allergies or special needs for Child (2)
Child (3) Name

First NameLast Name
Child (3) Age
Age
Gender:
Please list any allergies or special needs for Child (3)
Emergency Contact (1)

First NameLast Name
Emergency Contact (1) Phone Number

Area CodePhone Number
Emergency Contact (2)

First NameLast Name
Emergency Contact (2) Phone Number

Area CodePhone 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.
Emergency Medical Care: I authorize Kids in Action, in an emergency, to act in my behalf for my child's sake and to have my child transported to the nearest medical facility.
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.
I agree to have lotion applied to hands after washing (infants/toddlers ONLY)
I agree to have diaper cream applied during diapering (infants/toddlers ONLY)
List any and all previous illnesses, broken bones, surgeries, ect.
Does your child have any special needs the staff needs to be aware of (ADD, Autism, Epi-pen, speech, etc)?
If so, please explain:
Please list any other care instructions you wish to share:
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:
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Parent's Night Out$40.00
Child 1

Child 2$20.00
2nd child

Child 3$20.00
3rd Child

Child who is not potty trained$10.00
If first child is over age 1 and NOT potty trained

Infant$20.00

Total $0.00
Should be Empty:

Parent's Night Out

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