Parents' Night Out Child Registration Saturday September 26, 4:00pm-8:00pm
Please fill in the form below. Registration is $10 which can be paid through Realm. Please contact Angie Taylor (ataylor@mylhumc.org) for assistance or for more information.
Name of Parent/Guardian
*
First Name
Last Name
Parent/Guardian Phone Number
*
Format: (000) 000-0000.
Name of Additional Emergency Contact
*
First Name
Last Name
Relation to Child
Phone Number of Additional Emergency Contact
*
Format: (000) 000-0000.
Name of Child
*
First Name
Last Name
Age of Child
*
If child is less than one year please enter "1"
Allergies, Medications, Other Medical Alerts or Concerns
*
Name of Additional Child
First Name
Last Name
Age of Additional Child
If child is less than one year please enter "1"
Allergies, Medications, Other Medical Alerts or Concerns
Name of Additional Child
First Name
Last Name
Age of Additional Child
If child is less than one year please enter "1"
Allergies, Medications, Other Medical Alerts or Concerns
Name of Additional Child
First Name
Last Name
Age of Additional Child
If child is less than one year please enter "1"
Allergies, Medications, Other Medical Alerts or Concerns
Back
Next
Submit
Should be Empty: