Parent's Night Out Child Registration
Drop the kids off and have time for dinner or Christmas shopping. A gift from our youth!
Friday, December 7, 5:30 p.m. - 8:30 p.m.
Please feed dinner to children before dropping them off.
Snack provided: Goldfish, fruit, veggies and juice/milk. You are welcome to bring your own snack for your child if this does not work.
www.pleasantvalleyalive.org
Email address *
Child 1 Name and Age *
Your answer
Child 2 Name and Age
Your answer
Child 3 Name and Age
Your answer
Child 4 Name and Age
Your answer
Name of Parent/Guardian *
Your answer
Address *
Your answer
Cell Phone Number *
Your answer
Emergency Contact Name and Relation to child *
Your answer
Emergency Contact Phone Number *
Your answer
Does your child have any allergies, special dietary needs, or medical needs? Please explain in full detail: *
Your answer
My child may be photographed and their picture may be used on a participating church's website or in a slide show: *
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Pleasant Valley Church of the Brethren. Report Abuse - Terms of Service