PARENT LIBERTY NIGHT EARLY REGISTRATION ** $8 per hour per child paid in advance (no refunds) ** $28 for 3.5 hours ** or let us know how many hours your child will be staying for the event ** DROP IN FEE day of the event $10 per hour per child ** Ages 4 & Up - 6:30 pm - 10:00 pm
Start Date/Time: End Date/Time:
Fee per Student: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
Home Phone: Click to Enter an International Number Cell #: Click to Enter an International Number Work #: Click to Enter an International Number
Email:* (Emails are kept confidential)
Address: *
City: * State: * Zip: *
Emergency Contact Info*
Students entered below will be added to your family's account
How many hours will your child be attending? 1 hour, 1.5 hours, 2 hours, 2.5 hours, 3 hours or 3.5 hours*
Additional Information:
Other Questions/Comments:
Credit Card Verification:
Card Number: *  
Name as it appears on card: *
Card Expiration Month: *   Exp Year: *
Address Line 1: Address Line 2:
City: State: Zip:*