Registration
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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
Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Type
*
Doctor/Physician
Father
Grandparent
Guardian
Mother
Other
Parent
Step Father
Step Mother
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
*
State:
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NE
NC
ND
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
*
Emergency Contact Info
*
Students entered below will be added to your family's account
Add New Student #1:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Disabilites:
Allergies:
Medications:
Primary Doctor:
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Disabilites:
Allergies:
Medications:
Primary Doctor:
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Disabilites:
Allergies:
Medications:
Primary Doctor:
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Disabilites:
Allergies:
Medications:
Primary Doctor:
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Disabilites:
Allergies:
Medications:
Primary Doctor:
Questions/Options:
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:
*
Visa
Mastercard
Discover
Name as it appears on card:
*
Nickname:
Card Expiration Month:
*
01
02
03
04
05
06
07
08
09
10
11
12
Exp Year:
*
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
Address Line 1:
Address Line 2:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
VI
Zip:
*
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