Parents Day Out Registration Form

Parents Day Out Registration Form

December 19, 2025 from 1pm-4pm
Number of Children Registering
Name of Participant 1

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Grade Level
Name of Participant 2

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Grade Level
Name of Participant 3

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Grade Level
Name of Participant 4

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Grade Level
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone
Please enter a valid phone number.
Parent/Guardian Email
example@example.com
Emergency Contact Person

First NameLast Name
Emergency Contact Person Phone
Please enter a valid phone number.
Is your child / children experiencing any COVID-19 symptoms within 48 hours? Please select all the symptoms below (If none, please leave this field blank):

Temperature (100.4°F or higher)Nasal congestionRunny noseLoss of tasteLoss of smellDifficulty of breathingCoughSore throatHeadacheBody weaknessDiarrhea
Does the child / children have any food / other allergies

YesNo
If yes, please explain below. If none, please type N/A
Any mental or physical challenges we should be mindful of?

YesNo
If yes, please explain below. If none, please type N/A
Authorized Person Signature

Powered by Jotform SignClear
Date Signed

MonthDayYear
Date
Payment*
prevnext( X )
Child RegistrationMust check box to submit form. Registration is $25 per Child.
$25.00 Quantity

Total

$0.00
Payment Methods

Fastlane Checkout

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

Contact Info

Payment Info
Should be Empty: