Registration
Parents Night Out - December 1 - 5:30pm - 8:30pm Enjoy a night out while your kid enjoys and fun night of games and activities. Pizza and drink included.
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 (Not Contact #1 or #2)*
 
 
Students entered below will be added to your family's account
 
Additional Information:
 
Assumption of Risk
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I've read the above and agree.
 
Hold Harmless
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I've read the above and agree.
 
Release of Liability
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I've read the above and agree.
 
Illness
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I've read the above and agree.
 
Media Release
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I've read the above and agree.
 
Right to Refuse Service
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I've read the above and agree.
 
Safety Rules
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I've read the above and agree.
 
Enter your Full Name: *   
 
Other Questions/Comments:
 
Credit Card Verification:
   
Card Number: *  
Name as it appears on card: *
Nickname:
Card Expiration Month: *   Exp Year: *
Address Line 1: Address Line 2:
City: State: Zip:*
 
 
eCheck/Bank Draft:
Bank Name:
Bank Routing Number: (9-digit number)
Your Account Name: (Your name on your bank statement)
Your Account Type:   Account Number: