Clone of Child Care Registration Form

Parents Night Out

March 20th at GracePointe Church-207 S ave K from 5 PM to 8 PM
Information of Child
Child's Name

First NameAge
Additional Children:

First NameAge
Additional Children:

First NameAge
Additional Children:

First NameAge
Additional Children:

First NameAge
Additional Children:

First NameAge
Information of Parent
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Please list any food allergies below:
Important Information to know: 212 Youth is doing a fundraiser to raise money for youth camp. Donations are welcome! Pizza, waters & snacks will be provided.

*Childcare is $10 for the first child and $5 for each sibling. We can take cash Venmo, or cashapp.
Should be Empty:

Parents Night Out