Parents' Night Out Registration Form
Ages 1 and up
High Street United Methodist Church
Friday, March 1st, 2019, 6-9 pm
(Registration Deadline is Thurs, Feb 28th, 5pm)

Parent/Guardian Name (required)

Address (required)

Email Address (required)

Cell phone number (required)

Alternate phone number

You can register up to four children with one form.

First Child's Name (required)

First Child's date of birth (required)

First Child's Age (required)

First Child's Current Grade in School

First Child Potty Trained? (required)
YesNoIn progress

First Child Allergies/Medical Information/Other

Second Child's Name

Second Child's date of birth

Second Child's Age

Second Child's Current Grade in School

Second Child Potty Trained?
YesNoIn progress

Second Child Allergies/Medical Information/Other

Third Child's Name

Third Child's date of birth

Third Child's Age

Third Child's Current Grade in School

Third Child Potty Trained?
YesNoIn progress

Third Child Allergies/Medical Information/Other

Fourth Child's Name

Fourth Child's date of birth

Fourth Child's Age

Fourth Child's Current Grade in School

Fourth Child Potty Trained?
YesNoIn progress

Fourth Child Allergies/Medical Information/Other

Emergency Contact Information (required)

Emergency Contact Name

Emergency Contact Phone


Dismissal Information

Name(s) of person(s) who may pick up this child(ren) from Parents' Night Out

How did you find out about this event?
Word of mouthFacebookHigh St. UMC websiteRepeat visitorAttend High St. UMCOther (please specify):

By checking this box, I assume any risk of harm or injury which might occur to the participant in the event or activity. I release High Street United Methodist Church, its ministries, or volunteers from all liability, costs and damages which might arise from participation in the above activity. I agree that the above child may participate in Parent's Night Out. I further provide my consent to seek emergency treatment for the minor if necessary. I agree to accept financial responsibility for the costs related to the emergency treatment. I also agree that any photos, videos or statements of the above child taken during the event may be used for any and all promotional purposes by High Street United Methodist Church.

By checking this box, my child understands that if his/her behavior becomes problematic, he/she may be sent home at the discretion of the adult volunteers.