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

Day

Year

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 *