Parents Night Out Application Form
Parent Information
Parent's Name
First
Last
Email
Enter Email
Confirm Email
Phone
Children Attending
Child's Name
Allergies
Date of Birth
MM slash DD slash YYYY
Child's Name
Allergies
Date of Birth
MM slash DD slash YYYY
Child's Name
Allergies
Date of Birth
MM slash DD slash YYYY
Adults Allowed To Pick Up Children
Name
Phone Number
Name
Phone Number
Name
Phone Number
Consent
I Agree to the Following Policies
I understand that if my application is chosen that it is my responsibility to sign my child in and out from a VERDURE staff member's care. Adults other than parents who are authorized to pick up children must present a photo ID before the child is released into their care.
I understand that my child will not spend the entire time in the KidZone and may be in the sports arena and/or HIIT Zone for a portion of the night.
I give permission to VERDURE staff to provide dinner to my child and agree to alert VERDURE staff to any food-based allergies to which my child may be susceptible.
I understand that I will be charged the total amount upon registration. I acknowledge and consent to an additional $5 charge for every 5 minutes that I am late to pick up my child (beginning at 9:30 pm).
By checkingI, on behalf of myself and my listed child(ren), agree that the terms of my Membership Agreement with VERDURE shall apply to my child(ren)'s participation in Parent's Night Out, expressly to include the waiver and release of claims provisions contained therein.
I understand that I will be charged the total amount of registration and there will be no refunds for cancellations.
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Phone
This field is for validation purposes and should be left unchanged.
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