Parents Night Out 🎉

Parents Night Out 🎉

Register your child for a supervised night out and share any key details.
Parent/Guardian Full Name

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Child's Full Name

First NameLast Name
Child's Age
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Program Information
Will your child be attending:
Referral
How did you hear about Parents’ Night Out?

Other
Sibling Registration
Will you be registering additional children? (If yes, complete child information for each additional child.)
Health & Medical Information
Does your child have any food allergies or special instructions? No or Yes. If yes, please explain in detail below
Does your child have any medical allergies or special instructions? No or Yes. If yes, please explain in detail below
Does your child have any medical conditions we should know about? Examples:Asthma, Diabetes, Seizures, EpiPen, Heart condition, Other Please explain:
Will your child require medication during the event? No or Yes. If yes, please explain.
Development & Behavior
Has your child ever attended daycare, preschool, camp, or school before?
Does your child have any diagnosed medical, developmental, emotional, behavioral, or learning needs? Examples:• ADHD• Autism• Anxiety• Speech Delay• Sensory Needs• Other☐ No☐ Yes (Please Explain)
Are there any behaviors, emotional triggers, fears, or social concerns that would help our staff better support your child? Examples:• Difficulty separating from parents• Aggression• Elopement (running away)• Potty accidents• Difficulty sharing• Sensory sensitivities• Loud noises• Other. Please explain:
What strategies work best to help comfort or redirect your child if they become upset?
Bathroom Information
Is your child fully potty trained?
Does your child require assistance in the bathroom?
Health Screening
Has your child experienced any of the following within the last 48 hours?
Has your child been diagnosed with or exposed to any contagious or communicable illness within the past 14 days? Examples:• COVID-19• Influenza• RSV• Hand, Foot & Mouth Disease• Strep Throat• Chickenpox• Pink Eye• Other☐ No☐ Yes. If yes please include :Date: Illness:
Has your child been symptom-free for at least 24 hours without medication?
Food
Can you child eat pizza?
Type of pizza
Photo Release
Do you give Around The Clock Learning Center permission to photograph or record your child for social media and promotional purposes?
Pick-Up Authorization

Who is authorized to pick up your child?
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to the child:
Policies & Agreements

Please initial each statement as an agreement to the terms & policies.
My child is healthy enough to attend.
I understand payment is due before attendance.
I understand a $25 late fee deposit is collected at registration and will be applied toward any late pick-up charges.
I understand I will be charged $1 per minute after my selected pick-up time (10:00 PM or 12:00 AM if Extended Care is selected).
I understand that if I selected Extended Care, an additional $25 fee will be added.
I authorize staff to obtain emergency medical care if I cannot be reached.
I understand staff will contact me immediately if my child becomes ill or cannot safely participate. Around The Clock learning Center will try its best to accommodate you. We do reserve the right after a 30 minute grace period after being notified to have someone pick up my child before authorities be contacted for further assistance if a safety threat or concern to staff or other children in our care is an issue.
Additional Information
Anything else you’d like us to know about your child to help make tonight fun and successful?
Questions?

If you have any questions about Parents’ Night Out or would like to learn more about Around The Clock Learning Center’s childcare services, please contact us.📞 219-885-9293We look forward to providing your child with a fun, safe, and memorable evening while you enjoy a well-deserved night out! 💜💛🩵
Parent Signature
Please sign in your unique signature which includes: First & Last name, Birth Date & License Number
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Once your registration is reviewed, we’ll text you to confirm availability.
Should be Empty:

Parents Night Out 🎉

Program Information

Referral

Sibling Registration

Health & Medical Information

Development & Behavior

Bathroom Information

Health Screening

Food

Photo Release

Pick-Up Authorization

Policies & Agreements

Additional Information

Questions?

Parent Signature

Once your registration is reviewed, we’ll text you to confirm availability.