Parents' Night Out
Register your child below. Cost is $10 and can be paid when you drop off your child at church gym.
1st Child's Name *
Your answer
1st Child's Birthdate *
MM
/
DD
/
YYYY
Special information about child including allergies, special dietary restrictions, etc. *
Your answer
2nd Child's Name
Your answer
2nd Child's Birthdate
MM
/
DD
/
YYYY
Special information about child including allergies, special dietary restrictions, etc.
Your answer
3rd Child's Name
Your answer
3rd Child's Birthdate
MM
/
DD
/
YYYY
Special information about child including allergies, special dietary restrictions, etc.
Your answer
Parent's/Guardian's Name *
Your answer
Phone Number *
Your answer
Additional Phone Number
Your answer
Address
Your answer
Email
Your answer
Physician's Name & Phone Number
Your answer
Insurance Company & Policy Number
Your answer
I consent to have my child receive first aid by facility staff and, if necessary, be transported to receive emergency care. I will be responsible for all charges not covered by insurance. I understand and hereby agree to assume all of the risks which may be encountered during attendance at St. Luke's. I give my permission for my child to be photographed/videoed to promote St. Luke's Church programs. *
Type Signature Below
Your answer
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