Parents Night Out

Parent's Name

Parent's Phone

Parent's Email

This address will receive a confirmation email

Child's First and Last Name (Please list all children's names if more than one)

Child's Age (Please list all children's ages, if more than one)

Child's Grade (If applicable, please list all children's grades)

Dinner Plans:
Please be aware that the dinner provided for each child will be the following:
One piece of Little Caesar's pizza
One bag of chips
Bottled water
A sweet treat

**Should your child have food allergies, please indicate that below by listing which child has allergies and what it is he or she is allergic to. We do ask that you pack a dinner for that child so we can avoid cross contamination and care for him or her best.

Does your child(ren) have any food allergies?

Any other medical conditions we should be aware of?

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

February 15th, 2026 from 4pm-8:30pm at Calvary Chapel of Jacksonville, NC (1038 Henderson Drive, Jacksonville, NC 28540))

Note: This form will close and no longer be accepting sign ups at 4:25pm on the day of this event. Cash cannot be accepted at the door. All registrations will need to be through this form.

Parents Night Out

Description

Please Fix the Following