Lighthouse Church Parents' Night Out Child Registration Form
Please fill out one form for each child you are registering. Accepting potty trained kids only at this time
Name of Child
*
First Name
Last Name
Age of Child
*
Is your child potty trained?
Yes, my child is potty trained
No, my child is NOT potty trained (We are not allowed to change diapers so we are only accepting potty trained children at this time)
Name of Parent/Guardian
*
First Name
Last Name
Parent/Guardian Phone Number
*
Name of Additional Emergency Contact
*
First Name
Last Name
Relation to Child
Phone Number of Additional Emergency Contact
*
Name of Pick-up Person
*
First Name
Last Name
Relation to Child
Phone Number
Please enter a valid phone number.
Allergies, Medications, Other Medical Alerts or Concerns
*
By checking the box below I am virtually signing this document saying I grant permission for my child to participate in supervised activities, authorizer emergency medical treatment, and release Lighthouse Church from liability for any injuries or accidents.
I Agree
I do not Agree
Submit
Should be Empty: