2023 Parent's Night Out Sign-Up

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Parent's Night Out Registration

Child's full name: *

Parent/Legal Guardian Name: *

Child's DOB: *

YYYY

Child's Age: *

Street Address: *

Parent/Legal Guardian Phone number: *

Email Address: *

What dates are you interested in? *

March 25

April 29

May 27

Required

Participants may bring their own dinner or Nurturing families can provide dinner for a fee of $5 *

I will provide my child's dinner.

I would like to pay the dinner fee.

Other:

All children are required to bring: reusable water bottle with his/her name on it, Change of clothes and diapers/wipes if needed. *

I understand

Required

Please pick up you child promptly at the end of the program. Without prior communication, after a 5 minute grace period a late fee of $1 per minute will be charged. If a there is an emergency, please call the center to notify staff. *

I understand

Required

PERMISSION TO PHOTOGRAPH and RECORD AUDIO/VIDEO *

I consent to having my child's photo or video taken for educational training purposes only.

I consent to having my child's photo or video taken for promotional and marketing purposes

I DO NOT give Nurturing Families permission to photograph or take video my child.

Required

I give Nurturing Families consent to seek and accept medical treatment for my child. *

I consent

Required

Child's primary care physician and phone number. *

Does your child have any medical conditions, allergies or any special accommodations needed?

Emergency contact 1 : Name, relationship to child, phone number *

Emergency contact 2: Name, relationship to child, phone number. *

Diaper Changing Authorization. Depending on level of assistance needed, one to two staff members may be present during diaper changing and/or potty breaks. *

Diaper Changed

Toilet Trained

Toilet Training

Pull Ups

Assistance Wiping

We try to respect the participants boundaries and requests when it comes to personal space. We allow them to refuse to be changed if they clearly demonstrate and verbalize that this is their wish. Should your child refuse to be changed, please be advised that we will contact you to inform you as soon as possible *

Yes, allow my child to refuse and inform me

No, please change my child and/or encourage them to use the restroom

If I choose to withdrawal my child from Nurturing Families parent's night out program, payment and fees are non refundable without 30 days notice. *

I understand

Required

Payment is due 48 hours after invoices are sent. Failure to pay without communication will result in losing your spot. Invoices are sent via square. *

I understand

Required

Additional comments or concerns?

How did you hear about us? We would like to thank them!

Thank you for choosing to be apart of Nurturing Families programs. If you have any questions, please feel free to call or text Rachel at (360) 930-9468 or email admin@altavistalife.com.

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