Nuero Glow Parents

Nuero Glow Parents

2nd Wednesday of each month, 6:30pm-8pm, $15 per person (donations welcome), Lead by a licensed therapist, Child Care: $25 Per Child
What Wednesday date for Nuero Glow Parents are you signing up for?

MonthDayYear
Date
Is a child care needed?*

YesNo
Are you a KiDiMu member?*

YesNo
How many children are being registered?*

1234
Adult's name*

First NameLast Name
Adult's relationship to child(ren)*

MotherFatherOther
Adult's phone number*
Please enter a valid phone number.
Adult's email*
example@example.com
Adult's postal code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child 1's name*

First NameLast Name
Child 1's age*

2 1/234567891011121314Other
Child 1's grade*

PreschoolKindergarten1st2nd3rd4th5th6th7th8thOther
Child 1's allergies (If any)
Child 1's disabilities (if any)
Child 2's name*

First NameLast Name
Child 2's age*

2 1/234567891011Other
Child 2's grade*

PreschoolKindergarten1st2nd3rd4th5thOther
Child 2's allergies (If any)
Child 2's disabilities (if any)
Child 3's name*

First NameLast Name
Child 3's age*

2 1/234567891011Other
Child 3's grade*

PreschoolKindergarten1st2nd3rd4th5thOther
Child 3's allergies (If any)
Child 3's disabilities (if any)
Child 4's name*

First NameLast Name
Child 4's age*

2 1/234567891011Other
Child 4's grade*

PreschoolKindergarten1st2nd3rd4th5thOther
Child 4's allergies (If any)
Child 4's disabilities (if any)
Additional information (if any)
I grant permission to KiDiMu to use photographs or videos of myself and my child taken during museum visits or programs for educational or promotional purposes.*

YesNo
I am agreeing to KiDiMu's Health, Safety Policy, & Waiver. (Questions about policies & waivers can be directed to learnmore@kidimu.org)*

Yes
Signature*

Clear
Date*

MonthDayYear
Date

Payment*

Adult

$15.00 Quantity

Child

$25.00 Quantity

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Should be Empty: