Registration Form for Kids' Night Out (Feb. 10th from 5-9 pm) at St. Mark's Episcopal Church
Please complete this kids' night out registration form. We are eager to host your children and give you a night out.  This event is a fundraiser for the St. Mark's Church Youth Group to support the summer mission trip.  Childcare will be provided by teens and their adult mentors (who are all CORI-checked).

While the program runs from 5pm to 9pm, please feel free to drop off and pick up your child(ren) at the times that will work out best for your child's (children's) dinner and bedtime schedule in this time frame. We expect to serve dinner around 6pm. (We know that structure and routine are important for young children.)

For the younger children, (under age 4) please pack an extra set of clothes and diapers/wipes(in a labeled bag) if the child is not yet potty trained or still in training. That way we have a "back-up" if needed.

Please kindly fill out a separate form for each child.  Please direct any questions about the event to Melissa LaBelle (Youth Director) at 508-481-8278 or tobeslabelle@mac.com
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Email *
Come have a fun, kid-centered evening while parents get a date night!  : )
Parent or guardian's email and phone number *
Name of parent or guardian *
Child 's name
*
Child's age/grade
 *
Please indicate your dinner plan for your child. *
Dinner will be a pasta bar with options of butter, red sauce, and cheese. We will also offer healthy snacks of fruit and vegetables. Gluten free options will be available. We know that kids can sometimes be picky. Please feel free to send your child with alternate snacks or dinner options  (in labeled bag/lunchbox) if these plans are not ideal, and we will be happy to feed your child the alternative meal.
Permission:  By writing your name below, you are giving permission for adult volunteers and the St. Mark's youth group to supervise your child and take care of him/her/them during the kids' night out event. *
Risk/liability: Every effort will be made to provide a safe, structured, caring environment, yet there is always a risk when children engage in active events.  Do you acknowledge that there is the potential for injury even though a major priority will be given to promote safety and well-being of all students who attend? *
Required
In the case of emergency and medical attention needs to be attained, do you give us permission to seek medical help for your child if needed.  You will be notified if this is the case. *
Please list here any food allergies or dietary limitations for your child. Feel free to also mention any foods you would prefer for your child to NOT eat.  (Write N/A if this does not apply to your child.)
 *
Other needs:  Are there any other unique needs or concerns that we should know about in order to care for and support your child? These could include learning needs or disabilities, emotional needs, developmental needs, behavioral concerns, etc. (If there are none to note, please write N/A below.)
Parent/guardian phone number that can reached during the event (List whose number this is.)
 *
Emergency person to call in case provided number can't be reached. (Please provide name and number)
 *
Is your child going to be picked up BEFORE 9 pm? If so, please write yes below and indicate the time.  If your child will be picked up at 9pm, write N/A below. *
ALTERNATE PICK-UP/DROP-OFF: If there is an alternate adult (grandparent, sitter, older sibling, aunt, family friend) who is authorized to drop off or pick up your child, please list that person's name and cell number here.  (If this is not relevant to your family, please write N/A below.) *
OPTIONAL--Pleas list any additional comments, questions or concerns related to the kids' night out event here.
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