Parent/Guardian Information

Name

Phone Number

Child Information

Child Registration

Member ($15.00)
Non-member ($20.00)

Additional Siblings

($5.00/ea.)

Child Name

Child Date of Birth

Subtotal

$0.00

Please do not allow financial concerns to prevent your family from participating. For assistance, please contact Anna Iroff-Bailey, [email protected] or 690-6343 ext 3.

Emergency Contact

Emergency Contact (other than parent)

Emergency Contact Phone Number

Is there anything we need to know to make this program more comfortable for your family?

If you will be providing a separate meal for your child, please contact Anna Iroff-Bailey, [email protected] or 690-6343 ext 3

Coupon Code

Total

$0.00

Billing Information

Name

Cash/Check at Door

Credit Card
Cash/Check at the Door

Credit Card

Visa
Mastercard
American Express
Discover

Address

Event Registration Software by RegFox

Parents Night Out

Dinner & Childcare for ages 1-12

Parent/Guardian Information

Child Information

Emergency Contact

Billing Information