PARENTS NIGHT OUT REGISTRATION FORM

STUDENT REGISTRATION FORM

Director Contact: Krista Bailey, (972) 255-4185 or kbailey@ppumc.org
Child’s Name
Child’s Age
Child’s Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child’s Current Grade
Parent/Guardian Name(s)
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Mobile
Format: (000) 000-0000.
Email
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contact Method
Siblings registered
EMERGENCY CONTACT
Emergency Contact 1
Phone
Format: (000) 000-0000.
Emergency Contact 2
Phone
Format: (000) 000-0000.
Doctor
Phone
Format: (000) 000-0000.
Allergies or Special Needs
DISMISSAL
Who may pick up your child at the end of Parents Night Out?
Name
Relationship
Name
Relationship
Parent/Guardian Signature
My child will attend Parents Night Out on December (Cost is $10.00 per child or $25 per family max.) Fee covers program, supplies, and snacks
PHOTO RELEASE: Can your child be photographed, and the pictures appear in church news articles in print and on the internet/social media? (Pick One)
Participants T-Shirt Size?
Is there anything you would like for us to know about your child?
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Scholarships are available. Please contact Krista Bailey, Director of Children’s Ministry at kbailey@ppumc.org
PPUMC ● 1615 West Airport Freeway ● Irving, TX ● 75062 ● ppumc.org
Should be Empty:

STUDENT REGISTRATION FORM