Parents Night Out Info/Pay Form

Contact Email

Child's Name

Age & DOB (Must be at least 3 and potty trained)

Sex

Allergies or Special Needs

Anything we might need to know about your child:

Do you give permission for your child to:

Have their face painted

Have their nails painted

Watch a G-Rated Movie

Sibling 1 Name

Age & DOB (Must be at least 3 and potty trained)

Sex

Allergies or Special Needs

Anything we might need to know about your child:

Do you give permission for your child to:

Have their face painted

Have their nails painted

Watch a G-Rated Movie

Sibling 2 Name

Age & DOB (Must be at least 3 and potty trained)

Sex

Allergies or Special Needs

Anything we might need to know about your child:

Do you give permission for your child to:

Have their face painted

Have their nails painted

Watch a G-Rated Movie

Parent 1 Name

Parent 1 Phone

Parent 2 Name

Parent 2 Phone

Emergency Contact Name

Emergency Contact Phone

Select an item ($) *

Participant - $36

Participant + 1 Sibling - $56

Participant + 2 Siblings - $76

Participant + 3 Siblings - $96

Thanks for submitting!
We’ll contact this person only in case of emergency.

8201 Rowlock Way, Suite 116, Raleigh, NC 27612

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