A Night at Nineteen "Dancing in the Moonlight"
Event: Saturday, March 23rd 2024

Time: 6:00-8:00 PM

Location: 19 Hawthorne Event Venue
                  1000 Fetter Road
                   Lima, Ohio 45801

Contact: Rachael Staley (419) 303-8012              Cam Staley (419) 303-6759
                rstaley@acbdd.org                                   cmattstaley@gmail.com

Each guest (parent/guardian) must complete this form.

Ages 14-40

Parents/guardians/caregivers are required to stay with your attendee for the duration of the event in case of medical emergency. Please list your information below. 


Sign in to Google to save your progress. Learn more
Welcome to a Night at Nineteen All Abilities Prom!
Please complete the form below to register your guest. We look forward to all of our guests "Dancing in the Moonlight". 
Name of Guest *
Age of Guest
 *
Guest Gender
 *
Name of Parent/Guardian/Caregiver
 *
Parent/Guardian/Caregiver Phone Number
 *
Parent/Guardian/Caregiver Email Address
 *
I understand as a caregiver I need to remain with my attendee to be present in case of a medical emergency. 
 *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms