Parent's Night Out (Jan.)

Child's Information

Photo

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Child's Name

Date of Birth

Gender

Male Female

Does your child have any medical conditions we should be aware of?

Does your child have food allergies or dietary restrictions?

Dinner

Please provide pizza for my child I will send in dinner for my child

Parent/Guardian

First Name

Last Name

This address will receive a confirmation email

Phone

Address

Emergency Contact Information

Different than the parent information above.

First and Last Name

Phone number

Relationship to child:

Payment

Price is based on number of children being registered. PLEASE SELECT THE RIGHT AMOUNT.

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

1/18/25 4:00pm

We will have games, crafts, movies, pizza, and more. Each child will get a juice box, a slice of pizza, and a cookie. We will also have different snacks available. Of course, you are welcome to send in food.

We are building 5, Education door.

Parent's Night Out (Jan.)

Description

Please Fix the Following