Imagination Playhouse Date Night Waiver/Consent Form
This form will provide Imagination Playhouse with important information about your children. Please complete the form.
Email address *
Has you child been dropped off for date night previously? *
Child's Full Name (Child 1) *
Your answer
Child's Age *
Your answer
Child's Full Name (Child 2)
Your answer
Child's Age
Your answer
Child's Full Name (Child 3)
Your answer
Child's Age
Your answer
Child's Full Name (Child 4)
Your answer
Child's Age
Your answer
Are any of your children allergic to anything?
Please identify which child and what they are allergic to (food, etc.)
Your answer
Are any of your children taking any medication?
Imagination Playhouse does not administer or assist in the administration of any medications.
Your answer
Do any of your children have health limitations, dietary restrictions, or special needs? Any birthmarks or injuries we should be aware of?
Your answer
Additional information:
Your answer
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