Parent's Night Out 2019
Enjoy a night of free child care. For children ages 4-12. All participants must be potty trained.

Date: 11/1/2019
Time: 6:30 - 9:30
Location: QHC 65-15 164th St. Fresh Meadow NY 11365


Email address *
Child's Name 孩子的名字 *
Your answer
Age 年齡 *
Your answer
Parent Name 父母的名字 *
Your answer
Telephone 電話 *
Your answer
Email電子郵件 *
Your answer
Address 地址 *
Your answer
Emergency Contact Person 緊急聯繫人 *
If we can't reach the primary contact person
Your answer
Emergency Contact Number 緊急號碼 *
Your answer
Joining for Dinner 晚餐 6:00- 7:00 *
Allergy *
Your answer
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