👤 Child’s Information *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

👤 Child’s Information 2

If adding multiple children

First Name

Last Name

Date of Birth

MM

DD

YYYY

👤 Child’s Information 3

If adding multiple children

First Name

Last Name

Date of Birth

MM

DD

YYYY

👤 Child’s Information 4

If adding multiple children

First Name

Last Name

Date of Birth

MM

DD

YYYY

👤 Child’s Information 5

If adding multiple children

First Name

Last Name

Date of Birth

MM

DD

YYYY

Date of Birth

MM

DD

YYYY

👪 Parent/Guardian Information *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number (Primary) *

Country

(###)

###

####

Select event date(s)

November 7, 2025

November 21, 2025

December 5, 2025

December 12, 2025

December 19, 2025

🚨 Authorized Pick-up Representative (Other than Parent)

First Name

Last Name

Phone Number

Country

(###)

###

####

🧾 Does your child have any allergies? *

Yes

No

Any medical conditions, medications, dietary restrictions or special needs? *

Yes

No

Will your child eat the provided meal (e.g., pizza, fruit, water/juice)? *

Note: If sending food, it must be nut-free.

Yes

No

*

Brightwheel payment confirmation

*

I give permission for my child to attend and participate in Kids’ Night Out at Everyday Play N Learn at 10545 & 10529 Middleport Ln, White Plains, MD 20695.

*

I understand that while all precautions will be taken to provide a safe environment, I hereby release Everyday Play N Learn Child Development Center, its staff, and affiliates from any liability in case of injury, illness, or accident during the event.

*

I understand that I am responsible for picking up my child by 12:00 AM and may be contacted early if my child becomes ill or is unable to participate.

*

I authorize emergency medical care for my child in the event I cannot be reached.

*

I agree that any photos or videos taken may be used for social media or promotional purposes unless I opt out below.

Consent to photo/video use of my child. *

Yes

No

✍️ Acknowledgement & Signature *

I have read and agree to all terms above.

Date *

MM

DD

YYYY