Parents Night Out

September 20 @ 5:30 pm - 8:30 pm

| $3

Scholarships are available. Register below.

Parent’s Night Out Registration

Child's Name*
First Last
Child's Gender*
Child's Birthdate*
Month
Day
Year
What grade has your child completed?
Parent/Guardian #1*
First Last
Parent/Guardian #2
First Last
Home Address*
Street Address Address Line 2 City State ZIP Code
Primary Contact Number*
Cell Phone Number*
Emergency Contact Name*
First Last
Emergency Contact Number*
Authorized Pick-Up #1*
First Last
Authorized Pick-Up #2*
First Last
Do you attend Church?*
May we have permission to photograph your child?*
May we have permission to use your child's photograph in church publications?*
Does your child have any allergies?*
If yes, please list below.
Allergy List
Medical Conditions
Comments:

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