Kids Night Out Registration Form

Acton UMC Kids Night Out

It's really a parent's night out, but don't tell the kids! Have your kids, 4yrs-5th grade, join us on Friday night, February 20th, 6-9:00pm for an evening of fun! Dinner will be provided, and this event is free. Please call 317-862-2588 if you have any questions.
Registration

You can register up to 5 children in the same household on one form.
Parent/Guardian Information
Family Contact*

First NameLast Name
Phone Number*
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Information
Emergency Contact's Name (if parent cannot be reached)*

First NameLast Name
Phone Number*
Who is allowed to pick kids up besides parent or emergency contact?*

First NameLast Name
Attendee #1
Name*

First NameLast Name
Age*
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.*
Attendee #2
Name

First NameLast Name
Age
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Attendee #3
Name

First NameLast Name
Age
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Attendee #4
Name

First NameLast Name
Age
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Attendee #5
Name

First NameLast Name
Age
Does the child have any allergies, a chronic illness, or medical conditions? If yes, please describe.
Should be Empty:

Acton UMC Kids Night Out

Registration