2011 Parents Night Out Registration Form

Age _________ Grade __________________

Street Address _________________________________________

City _______________________ State ______ Zip ___________

Home email address _____________________________________

Date of Birth ___________________

Home Church __________________________________________

If none, may we contact you with all that PGPC has to offer? Yes   No

Will someone else pick up your child? Yes    No

If so, who? ____________________________ Relationship____________

Have you filled out your Emergency Medical Form? Yes      No

If not, please print form, complete and bring with you (extras will be available)

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