Parent Night Out Registration
Need a night out to relax, shop or catch a good movie?We invite you to bring your children (ages KG-5th grade) to a safe, supervised and exclusive time of food, games and movies.**Only pre-registered children will be allowed. Spaces are limited**
Youth (1) Information
*
First Name
Last Name
Grade (KG-5th Grade)
*
Gender
*
Male
Female
Youth (2) Information
First Name
Last Name
Grade
Gender
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Information
Name
*
First Name
Last Name
Cell Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Emergency Information
Emergency Contact's Name
*
First Name
Last Name
Relationship
*
Please Select
Mother
Father
Grandparent
Aunt
Uncle
Sibling
Babysitter/Nanny
Other
Phone Number
*
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Does the youth have any allergies, chronic illness, or medical conditions? If yes, please describe.
*
Submit
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