Registration

Parent's Night Out Fridays from 7:00pm to 10:30pm

Event:

Start Date/Time:

End Date/Time:

Fee per Student:

Room:

* - denotes required fields

Family Information

	First Name:*	Last Name: *
	Type*
	Home Phone:*	Cell #: Work #:
	Email:*	(Emails are kept confidential)

	Address: *
	City: *	State: * Zip: *
	Emergency Contact Info

Students entered below will be added to your family's account

Add New Student #1:

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	Student's First Name: *	Last Name: *
	Student Gender: *	Birth Date: * (format=mm/dd/yyyy)
	Student Email:
	School:	Grade Level:
	Disabilities (Leave blank if NONE):
	Allergies (Leave blank if NONE):
	Medications (Leave blank if NONE):
	Primary Doctor:

Questions/Options:


Will you be picking up your child?*
If no, who will be picking up your child?
Does your child have any allergies? If yes, please state below.*

Additional Information:

Appreciation of Risk:

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I've read the above and agree.

Medical Release Statement:

(Show-Hide Details)

I've read the above and agree.

Enter your Full Name: