Parents Night Out Registration Form

April 21, 2017 5:00-9:00 PM

This form must be turned in along with a minimal $10 donation to
American Cancer Society.

My child, ____________________, will attend Treat for a

Treatment, Parents Night Out, sponsored by Emily
Stevahn. This event runs 5:00-9:00 PM on April 21st at
Kingston Elementary School.
Participation Information:
Students Full Name ____________________________________
Teachers Name __________________ Grade ______
Parents name__________________________ Phone
________________
Medical conditions, including allergies:
_____________________________________
Other important information: -
_____________________________________________
Emergency Contact: Name and Phone ______________
_________________________
Student will be picked up by:
________________________________________________
Registration Agreements:
1. Student safety is a top priority. All participants must adhere to
VBCPS Code of Conduct. This optional event is handled by First
Colonial High School volunteers. Any student who is unable
behave appropriately or follow the rules will need to be picked up
promptly.
2. Pizza will be provided from Dominos Pizza. A snack (chips) and
water bottle will also be provided.
3. Students need to be picked-up promptly by 9:00 p.m. in the
cafeteria foyer. Students can only be released to their parent(s)
unless prior written arrangements have been made.
4. A minimal $10 donation per child (preferably cash) should be
turned in with this registration form or turned in at student sign-in
on the evening of April 21st.
 5. Pictures will be taken at the event to document the project
and will be used in the educational presentation only. Student
names will NOT be used.
By signing below, you and your student commit to the Registration
Agreements stated above:
________________________________ ___________________________________
Students Signature Parents
Signature
Please turn this form into the Main Office on or before Wednesday April
19th.