Parents' Night Out Registration Please complete the following information for each child who will be attending Parents' Night Out. Child's Name * Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039 Allergies or Special Needs Address * City, State and Zip Code * Parent/Guardian Information Parent/Guardian Name * Address (if different than listed above) City, State and Zip Code Home Phone Number Cell Phone Number * Email Address Who will be picking up the child from Parents' Night Out * Driver's License Number * Emergency Contact Name, Phone Number and Relationship *