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Parents Night Out - Registration
Now Registering for our NEXT PNO event! FRIDAY - SEPTEMBER 6th

PRICING: $20 (1st child) - $15 (each additional sibling)
Times: 6:00 - 9:00 pm
Ages: 3 (Potty trained is Required) to 10 year olds are welcome

Dinner Menu: Pizza, fruit, drink, and a special treat!

Space is limited so register early to save your child's spot. Please complete the form in full, and payment must be received to secure your child's spot in our PNO events.

Kids will enjoy play, crafts, games, social interaction, a full dinner, and movie with popcorn! We hope your kids can join us for learning, play and fun at eTeachingMe!
Parents/Guardian First & Last Name *
Your answer
Phone Number 1 *
Your answer
Email Address *
Your answer
Home Address *
Your answer
Child #1 Enrolling: Name *
Your answer
Your answer
Current Age of Child #1 *
Allergies, Needs, or Medical Conditions (If none, type N/A) *
Your answer
Child #2 Enrolling: Name
Your answer
Your answer
Current Age of Child #2
Allergies, Needs, or Medical Conditions (If none, type N/A)
Your answer
Additional Childr(en) Enrolling
If none - leave blank. Please list any additional child(ren) you are wanting to enroll in camps. List their NAME, DOB, Current AGE, and any ALLERGIES they may have.
Your answer
Dinner for your kids *
Please refer to the dinner menu items that will be served during this PNO event at the very top of this form - where the PNO information is displayed. If you have any requests, restrictions, or concerns about any of the food/drink items that will be served to your child, please check whether you allow or do not allow any of these items to be served. We do allow parents to bring in brown-bag dinner from home for their child, if necessary & preferred due to such food preferences, allergy reasons, or restrictions. Thank you.
Emergency Contact *
In case of an emergency situation, please list one local person that we can contact other than the parents/guardian listed above.
Your answer
Emergency Contact Phone # *
Your answer
Emergency Contact Relationship to Child *
Is this person also Authorized to Pick-up your child? *
Note: All authorized to pick-up are required to show a valid photo ID at the time of pick-up, and must be 18 years or older.
Physician's Name *
Your answer
Physician Phone Number *
Your answer
Preferred Hospital *
Note: Due to the nature or circumstance of an emergency medical situation, eTeachingMe has the right and authority to contact local medical emergency support, and patient will be transported to the nearest hospital.
Your answer
Tell us How.... *
We love to know where our families come from. Please select how you heard or found out about us below!
Drop off & Pick up Policy *
For all camps and day kid-events, parent or guardian is required to drop child off at beginning of event time and efficiently pick up the child/person at the end of event time. There will be a late charge of $10 for every 15 minutes that pick-up time is late. Due to our program needs, we enforce this policy to properly and efficiently manage our class’s schedules and the needs of all of our students.
Medical Emergency Consent *
By signing your name below, you are agreeing and understand the following. I, the undersigned parent or guardian of the above named student, do hereby grant authority to the staff of eTeachingME to render judgement concerning medical assistance in the event of an accident, injury, or illness during my absence.I give my consent for my family doctor to treat my child in case of emergency or if you are unable to contact him, please accept this form as your authority to use the doctor on call in the emergency room for any necessary emergency medical treatment.I also understand that in this instance, I will be notified by phone in regards to the situation, and I give permission for my child to be transported to the nearest medical center if treatment is needed.
Your answer
Payment Policy Consent *
I understand that there is a $20.00 fee for my child (siblings $15/each) who attends PNO at eTeachingMe. I understand that payment must be paid in full in order to hold my child's spot. If payment is not received, the student may not be able to attend the event, and their spot may be given to another student on the wait list. I understand that all fees are non-refundable.
Credit Card Policy *
By submitting my credit card information through the secure online registration process using the PayPal payment processing system, I authorize eTeachingMe to automatically charge my card for the full camp fees posted, as a one-time charge.
Photo Release Statement *
I grant/do not grant eTeachingMe the right to take photographs/videos of my child. I agree that eTeachingMe may use such photographs or videos for any lawful purpose; including such purpose as publicity, illustration, advertising, social media postings, or on our website for camp illustrations.
Release of Liability *
By reading and signing this form, you are agreeing and aware that you are engaging in activities with Love N Learn At Home, LLC dba eTeachingMe that include but are not limited to physical exercise and use of equipment, facilities, training and learning instruction. Some of our activities could cause injury to you or others. You are voluntarily participating in these activities and assume all risks of injury and liability that might result. You agree to waive any claims or rights you might otherwise have to pursue, Legal or other action against Love N Learn At Home, LLC dba eTeachingMe, the facility's owners, officers, employees, or agents for any reason. You have carefully read this waiver and declare you are sufficiently physically fit for any of our activities in which may require physical abilities and exercise.
Signature of authorized parent/guardian *
By signing below, you are agreeing to register the above named child/person for our enrichment learning classes, events, or camps. You have read and fully understand all class details, descriptions, and policies as stated above. This signature verifies understanding and acceptance of this registration.
Your answer
Signed this day
Signed at this time
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