Parents Night Out Registration Form

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Need a break from the kids? We will take care of them! Take a night off, and leave your child(ren) with us from 6PM to 9PM! We'll have FOOD and FUN ACTIVITIES to keep your kid(s) occupied. Please complete the registration form to enjoy your night off!

$25 for first/one child...$20 per each additional child

Venmo @Kristy-Davies-1

PayPal @SpeechLanguageAssocNJ

Located at Elevate Health & Therapeutic Services:

1124 Patriot Way

Eastampton, NJ 08060

Email *

Parent's Name *

How many children will you be dropping off? *

Kid(s) Name(s) *

Any food allergies? Please specify that child's name.

Which Friday(s) are you registering for? *

Feb 23

March 22

April 19

Required

Is there anything else we should be aware of? *

How did you hear about our event? *

I understand registration is not complete without payment received ($20 for each additional child) *

I understand registration is not complete without payment received ($20 per each additional child)

I understand that I have to pay through Venmo/PayPal prior to entry. (Venmo @Kristy-Davies-1) (PayPal @SpeechLanguageAssocNJ) *

I understand that I have to pay through Venmo/PayPal prior to entry.

Submit

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