Parent's Night Out
 Space is limited- Students enrolled on a first come first serve basis
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Email *
For which month are you registering?  *
Student First and Last Name *
If you are registering siblings, please add their names below. Example:
Maya Vasilez and Erik Vasilez
Date of Birth *
Tribal Affiliation *
 First Name Last Name of Parent/Guardian/Caregiver *
Address *
Telephone Number *
Emergency Contact: First Name Last Name  *
Emergency Contact: Phone Number *
Is there anyone who cannot have contact with your child? If so please list their name. *
Does your child have health conditions or allergies that we should be aware of? *
Please describe these health conditions or allergies. *
Does your child attend a preschool currently?  *
Is your child potty trained? *
Does your child have any special needs, such as, academic, behavior, physical, or social emotional needs?  *
In the event of an emergency, are you allowing the teachers to make medical decisions for your child?  *
Who is your child's doctor?  *
Which hospital do you prefer in the event of an emergency? *
What type of health insurance do you use? *
Sign below by typing your name: *
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