Parents Night Out Registration Form

Parents Night Out Registration Form

FUNDAY FRIDAY!!
FRIDAYS DURING THE SUMMER

Gym - Crafts - Play

Children: 3 years and older

(must be potty trained)

Hours: 9:30-11:30 am

__________________________________________________________________________________

Pricing: $40/child

Payment is due when registration is processed and confirmed.

Each child must have a signed policy form on file.

Cancellation Policy: Payment is refunded minus $10 transaction fee for cancellations up until 24 hours prior to event. For cancellations within 24 hours, 50% of payment will be refunded.
Child Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Gender
Is there anything we need to know about your child?
2nd Child's Name

First NameLast Name
2nd Child's Date of Birth

MonthDayYear
Date
2nd Child's Age
2nd Child's Gender
Is there anything we need to know about your second child?
3rd Child's Name

First NameLast Name
3rd Child's Date of Birth

MonthDayYear
Date
3rd Child's Age
3rd Child's Gender
Is there anything we need to know about your third child?
Parent/Guardian Information
Parent/Guardian Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship

Adults Authorized to pick up your child

Rows	First & Last Name
Adult #1
Adult #2
Adult #3
Adult #4

Payment & Confirmation
Please indicate which date(s) you are enrolling:
If you have any difficulties, please email therapywest2@gmail.com
Cancellation Policy: Payment is refunded minus $10 transaction fee for cancellations up until 24 hours prior to event. For cancellations within 24 hours, 50% of payment will be refunded.

My Products

June 5, 2026$40.00

Number of Kids
Item subtotal:

June 12, 2026$40.00

Number of Kids
Item subtotal:

June 19, 2026$40.00

Number of Kids
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June 26, 2026$40.00

Number of Kids
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July 10, 2027$40.00

Number of Kids
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July 17, 2026$40.00

Number of Kids
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July 24, 2026$40.00

Number of Kids
Item subtotal:

July 31, 2026$40.00

Number of Kids
Item subtotal:

August 7, 2026$40.00

Number of Kids
Item subtotal:

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Parent/guardian Signature
Date Signed

MonthDayYear
Date
Should be Empty: