Hog Wild Watch Party Registration (Kids Night Out)

"*" indicates required fields

Step 1 of 10 – Child Information

Child Basic Information

Child's Name*

First Last

Birth Date*

Child's Age*

Grade (24-25)*

Child Medical Information

Allergies? ("na" if none)*

Please list any pertinent information that may help us properly care for your child in our program (Including Relevant Medical Information, Medicine Currently Taking, Emotional Needs, Social Needs, etc.)

Other Conditions or Comments?

Primary Parent/Guardian Information

Primary Parent/ Caregiver Name*

First Last

Relationship to child:*

Primary Parent/ Guardian Cell Phone*

Home Address*

Street Address City State ZIP Code

Primary Caregiver Email*

Secondary Parent/Caregiver Information

Secondary Parent/Caregiver Name

First Last

Relationship to child:

Secondary Caregiver Cell Phone

Home Address

Street Address Address Line 2 State ZIP Code

Secondary Caregiver Email

Emergency Contact Information

Emergency Contact Name*

First Last

Phone Number*

Relationship to Child*

Is The Emergency Contact Authorized To Take Your Child From FAC?*

In The Event Of An Emergency

Hospital Emergency Room of Choice:*

Phone Number of Emergency Room Choice*

List any other adults who are authorized to take the child from the center:

Name

First Last

Cell Phone

Relationship

Name

First Last

Cell Phone

Relationship

Name

First Last

Cell Phone

Relationship

Hog Wild Watch Party Registration (Kids Night Out)

Child Basic Information

Child Medical Information

Second Child Basic Information

Second Child Medical Information

Third Child Basic Information

Third Child Medical Information

Fourth Child Basic Information

Fourth Child Medical Information

Primary Parent/Guardian Information

Secondary Parent/Caregiver Information

Emergency Contact Information

In The Event Of An Emergency

List any other adults who are authorized to take the child from the center:

Policies & Waivers

Billing Information

A Place Where You Belong