JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Parents Night Out Registration
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Parent/Guardian Name:
*
Your answer
Child 1 Name:
*
Your answer
Child 1 Age:
*
Your answer
Child 2 Name:
Your answer
Child 2 Age:
Your answer
Child 3 Name:
Your answer
Child 3 Age:
Your answer
Email Address:
*
Your answer
Home Address:
*
Your answer
City/State
*
Your answer
Zip Code:
*
Your answer
Home Phone #:
Your answer
Cell Phone #:
*
Your answer
Emergency Contact Name & Phone #
*
Your answer
Child's Physician's Name:
Your answer
Child's medical concerns of which we should be aware:
Your answer
Allergies/Dietary Restrictions
Your answer
I authorize medical treatment for my child in case of an accident or illness if the parent or guardian cannot be located and an emergency situation arises
*
I Agree
I Do Not Agree
Required
Do you authorize any other adults to pick up your child? If yes, Please list names below:
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Hamptons UMC.
Report Abuse
Forms
