Kids Night Out at IGNITE

kids Night Out at IGNITE Dance & Yoga

Hosted By Community Connections
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Email
example@example.com
Phone Number
Mobile Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Kids Night Out

Saturday, March 1stSaturday, April 5thSaturday, May 3rdSaturday, June 7th

Can your child be photographed for our social media page?

YesNo
Medical Information
Does the child have allergies including asthma?
Please explain on the field provided including any food the camper is allergic to

Contact Information in Case of Emergency
Name

First NameLast Name
Contact Number
Relation to child
Name

First NameLast Name
Contact Number
Relation to child

Payment
The amount that appears below is the total amount. Please use code(15) for registering multiple children. Each child will need their own registration form filled out. This is non-refundable but may be transferend to another kids night out date should an unforseen circustmace occur, including illness.

My Products

Kids Night

$55.00

Product Name

$ Free Quantity

Enter coupon

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty: