Kids Night Out
Parent #1 Information
First Name
*
Last Name
*
Relationship to Child
*
Mother
Father
Email Address
*
Cell Number
*
Parent #2 Information
First Name
Last Name
Relationship to Child
Mother
Father
Email Address
Cell Number
Child Information
Child First Name
*
Child Last Name
*
Age (during the event)
*
4
5
6
7
8
9
10
11
12
School Grade
*
-- None --
Infants/Toddlers
Pre-K
Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
Gender
*
Male
Female
Allergies
*
No Allergies
Peanuts
Tree Nuts
Dairy
Gluten
Bee Stings
Other
Additional Allergies
Please indicate if your child has an Epi-pen.
*
Yes
No
Allergy Explanations
We will be providing dinner. Please indicate below if you would prefer to provide your own:
*
Thank you for providing a meal for my child.
I will be providing my child with his/her own meal.
Face painting will be available. Please indicate below if you do not want your child to have their face painted:
*
Yes - my child may have his/her face painted.
No - my child may not have his/her face painted.
Additional Information:
Drop-off / Pick-up
If someone other than a parent listed above is dropping off or picking up your child(ren), please provide their information below.
Name
Phone Number
Relationship
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