PARENTS' NIGHT OUT REGISTRATION

Please fill out the form below to register your child for our Parents' Night Out event.

We will contact you to confirm registration and to schedule payment.

 
Name *
Name
Phone *
Phone
Child's Name (1)
Child's Name (1)
Does your child use verbal communication? *
Does your child engage in any aggressive behaviors? *
Does your child have sensory sensitivities? *
Does your child have any allergies (food or other)? *
Child's Name (2)
Child's Name (2)
Does your child use verbal communication?
Does your child engage in any aggressive behaviors?
Does your child have sensory sensitivities?
Does your child have any allergies (food or other)?
In the event my child(ren) need(s) to use the bathroom, I give Believe in Me consent to assist in toileting/changing diaper(s). *
As the legal guardian of the child(ren) listed above, I consent to having photos taken during the event. *
I would like to pay by: *