Parents' Night Out Sign Up (June)
Choose from the dates below for your ticket to a kid free night! 

Dates: 

Saturday, June 1st (4:00-8:00) Movie Night
  • Price: $50 (includes pizza for supper and all activities)
Friday, June 7th (5:00-8:00) Game Night
  • Price: $40 (includes pizza for supper and all activities)

Our price lowers by $10 for any additional kids you sign up. 

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Dates (Please choose as many dates as you would like to sign up for) *
Required
Child 1 Name & Age (First, Last, Age)  *
Child 2 Name & Age (First, Last, Age) 
Child 3 Name & Age (First, Last, Age) 
Child 4 Name & Age (First, Last, Age) 
Parent Name (First & Last)
Parent Email Address *
Primary Emergency Contact Name (First and Last/Relation) *
Primary Emergency Contact Phone Number *
Secondary Emergency Contact Name (First and Last/Relation) *
Secondary Emergency Contact Phone Number *
Health Concerns (allergies, medical, etc) *Please specify which child*

If none please state n/a
 *
Other Concerns/Important Information (Family, behavior, etc) *If none please state n/a *
Please read the following consent and mark yes or no. 

I give consent to Little Learners Academy for my child to be transported and receive medical aid as may be necessary and expedient by a licensed physician/surgeon in case of an emergency when parent/guardian cannot be reached. 
 *
Please read the following consent and mark yes or no.

I give consent to Little Learners Academy to use photographs or videos of my child for any legal use including but not limited to: publicity, copyright purposes, advertising, and web content. 
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I would like to pay using the following method
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