Kids Nite Out Registration: Kids Nite Out Registration

KIDS NITE OUT
Friday, November 21st
6:00pm - 10:30pm
Open to Birth - 5th Grade

$8 per child or $16 max per family
Pizza Dinner Provided, Activites & A Movie

Registration Deadline is November 19th at 5pm OR when we reach a maxium of 50 Kids.

Questions? Leslie Roach,
799-3621, leslie@wpclubbock.org

Kids Nite Out Registration: One Form Per Family

* Child(ren) Name  
* Age(s)  
Grade(s)  
* Parent's Name  
* Address  
* City  
* ZipCode  
* Cell Phone #  
* Home Phone #  
* Email Address  
* Emergency Contact #1 other than a Parent (phone # and relation)  
* Emergency Contact #2 other than a Parent (phone # and relation)  
Please let us know if there are any special needs your child(ren) might have.