Parent's Date Night Out

Parent Name

Parent Email

This address will receive a confirmation email

Parent Phone Number

Address

Please list the name, grade and age of each child attending.

Please list allergies, medical concerns, or other concerns we should know about. If are there none, please type "none."

Please list at least two emergency contacts with phone numbers.

How did you hear about Parents Night Out?

Payment: $10 per child, $10 for each additional child, maximum of $50 per family.

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

February 14, 5:30-8:30 pm

Birth to 5th grade
The cost is $10 per child, $10 for each additional child, with a family maximum of $50. The evening includes childcare, dinner and dessert, a craft, and free play, and ends with a movie.

Registration is non-refundable.

Parent's Date Night Out

Description

Please Fix the Following