Kids Night Out Registration 2025 Kids Night Out Registration "*" indicates required fields Step 1 of 10 – Child Information 10% Child Basic InformationChild's Name* First Last Birth Date* MM slash DD slash YYYY Child's Age*Grade (24-25)* Event(s) Attending* Hog Wild Watch Party (Sept 6, 2025) Slime FACtory (Oct 18, 2025) Fall Fest Frenzy (Nov 22, 2025) Rudolph’s Drop & Shop (Dec 13, 2025) Select AllRegister for all 4 kids night out events and receive $5 off each event.Child Medical InformationAllergies? ("na" if none)* Please list any pertinent information that may help us properly care for your child in our program (Including Relevant Medical Information, Medicine Currently Taking, Emotional Needs, Social Needs, etc.)Other Conditions or Comments? How Many Additional Kids Would You Like to Register?0123 Second Child Basic InformationChild's Name* First Last Birth Date* MM slash DD slash YYYY Child's Age*Please enter a number from 1 to 12.Grade (24-25)* Event(s) Attending* Hog Wild Watch Party (Sept 6, 2025) Slime FACtory (Oct 18, 2025) Fall Fest Frenzy (Nov 22, 2025) Rudolph’s Drop & Shop (Dec 13, 2025) Select AllRegister for all 4 kids night out events and receive $5 off each event.Second Child Medical InformationAllergies? (na if none)* Please list any pertinent information that may help us properly care for your child in our program (Including Relevant Medical Information, Medicine Currently Taking, Emotional Needs, Social Needs, etc.)Other Conditions or Comments? Third Child Basic InformationChild's Name* First Last Birth Date* MM slash DD slash YYYY Child's Age*Please enter a number from 1 to 12.Grade (24-25)* Event(s) Attending* Hog Wild Watch Party (Sept 6, 2025) Slime FACtory (Oct 18, 2025) Fall Fest Frenzy (Nov 22, 2025) Rudolph’s Drop & Shop (Dec 13, 2025) Select AllRegister for all 4 kids night out events and receive $5 off each event.Third Child Medical InformationAllergies? (na if none)* Please list any pertinent information that may help us properly care for your child in our program (Including Relevant Medical Information, Medicine Currently Taking, Emotional Needs, Social Needs, etc.)Other Conditions or Comments? Fourth Child Basic InformationChild's Name* First Last Birth Date* MM slash DD slash YYYY Child's Age*Please enter a number from 1 to 12.Grade (24-25)* Event(s) Attending* Hog Wild Watch Party (Sept 6, 2025) Slime FACtory (Oct 18, 2025) Fall Fest Frenzy (Nov 22, 2025) Rudolph’s Drop & Shop (Dec 13, 2025) Select AllRegister for all 4 kids night out events and receive $5 off each event.Fourth Child Medical InformationAllergies? (na if none)* Please list any pertinent information that may help us properly care for your child in our program (Including Relevant Medical Information, Medicine Currently Taking, Emotional Needs, Social Needs, etc.)Other Conditions or Comments? Primary Parent/Guardian InformationPrimary Parent/ Caregiver Name* First Last Relationship to child:* Primary Parent/ Guardian Cell Phone*Home Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Caregiver Email* Secondary Parent/Caregiver InformationSecondary Parent/Caregiver Name First Last Relationship to child: Secondary Caregiver Cell PhoneHome Address Street Address Address Line 2 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Secondary Caregiver Email Emergency Contact InformationEmergency Contact Name* First Last Phone Number*Relationship to Child* Is The Emergency Contact Authorized To Take Your Child From FAC?*YesNoIn The Event Of An EmergencyHospital Emergency Room of Choice:* Phone Number of Emergency Room Choice*List any other adults who are authorized to take the child from the center:Name First Last Cell PhoneRelationship Name First Last Cell PhoneRelationship Name First Last Cell PhoneRelationship Policies & WaiversPhoto/Video AuthorizationWe will be taking pictures throughout the year to capture the action and adventure of our Kids FACtory programs. I hereby grant permission to Fayetteville Athletic Club to use photographs and/or video of my child(ren) taken during FAC programs, in publications, news releases, online, and in other communications related to the Kid FACtory programs. I have reviewed the above photo/video authorization and grant permission (Do not check this box if you do not grant permission)FAC Waiver Release Statement*I agree to the Fayetteville Athletic Club’s Waiver release statement. By signing this form, I understand that I am releasing all claims for injury, I or my child may sustain through any of our programs. I agree to assume full risk and to waive, relinquish, and release all claims I and/or the participant may have against, indemnify, hold harmless and defend the Fayetteville Athletic Club. This release includes FAC officers, agents, servants, and employees from such claims resulting from injury, damages, or loss sustained while participating in the FAC program or event. I understand that I am responsible for all personal insurance and understand that I must cover any medical costs incurred for my family participating in this FAC program. I also understand that every precaution is taken to protect the safety of each participant. I’ve reviewed the above statement and agreeMedical Emergency Consent*I, (mother/father/guardian), do hereby give my consent to the Director of the Child Care facility, or his/her representative, for said child to receive medical or surgical aid as may be deemed necessary and expedient by a duly licensed or recognized physician or surgeon in case of emergency when parent/guardian can not be reached. Consent is also given for the Director or his/her duly appointed representative to transport said child for emergency medical treatment, if the parents cannot be reached. Please sign below. I’ve reviewed the above statement and agreeFAC Kids Night Out Billing Policy*The payment for the event must be paid by October 1st in order to register your child(ren) for the FAC Kids Night Out Event. The balance will be billed the Friday prior to the event. This balance must be paid by a credit card or bank account on file with FAC. Payments must be received for your camper to attend the Kids Night Out Event. Non-payment by the required due dates will result in relinquishing the camper’s space in the event. FAC Junior Membership or enrollment in the FAC After School Program is required for each child to receive the Member discount for the Kids Night Out event. Changes or cancellation requests must be received a minimum of 5 days prior to the event and must be made in writing to the Director. FAC member discounts will be voided, and additional charges will occur if the FAC Junior membership is canceled at any time during the program duration. A $25 returned payment fee will be applied to any returned payments. Fayetteville Athletic Club accepts, Visa, Master Card, Discover, American Express, bank drafts and checks. I agree to abide by the Billing policy that has been presented. I’ve reviewed the billing policy above and agree Billing InformationCredit Card Number*Credit Card Type*VISAMastercardDiscoverAmerican ExpressExpiration Date* CVV* Name on Credit Card* First Last
