Parent's Night Out December 16, 2017
Please complete the form below prior to Date Night.
Email address *
Child's First and Last Name *
Your answer
Age of Child *
Your answer
Please list any allergies: *
Your answer
Parent's First and Last Name *
Your answer
Parent's Cell Phone Number *
Your answer
Parent's Alternate Phone Number
Your answer
Address *
Your answer
Emergency Contact (other than parents) *
Your answer
Relationship to Child *
Your answer
Emergency Contact Cell Phone Number *
Your answer
Name and age of Sibling Attending
Your answer
Allergies:
Your answer
Name and age of Sibling Attending
Your answer
Allergies:
Your answer
Name and age of Sibling Attending
Your answer
Allergies:
Your answer
I understand that Parent's Date Night is a Fundraising Event for the Bethel Youth Group *
I understand that my child(ren) will be in the care of the Bethel Youth and at least one adult. *
Required
I understand that my children are to be dropped off at Bethel no earlier than 5:30 pm and picked up no later than 9:00 pm on Date Night. *
Any special things you would like us to know about your kiddo(s) ?
Your answer
If you have any questions, please contact Bethel's Family and Children's Ministry Director, Mandy Toms. Her e-mail is mandybethelwindsor@gmail.com
A copy of your responses will be emailed to the address you provided.
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