Parent Night Out Emergency Contact Information

Dear Parents,

Thank you for entrusting us with your precious children for our Parents' Night Out event. We want to ensure that your children have a safe and enjoyable time, and that you have peace of mind while you are away.

Please complete this form with your most up-to-date emergency contact information. This information will be kept on file in case of an emergency.

* Indicates required question
Email *
Your answer
Child(ren)s name (first and last) and date of birth.
Example: John Doe 08/08/2008
 *
Your answer
Address *
Your answer
Parents name (first and last) and relationship to child(ren)
Example: Jane Doe- Mother
 *
Your answer
Phone number while you are out today. *
Your answer

Please list any allergies or medical conditions your child may have:

Please list any medications your child is currently taking:

Please provide any additional information that you think may be important for us to know:


If none please type N/A or NONE

 *
Your answer
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