Name: Mom and Me Night Out
Start: 2025-05-15T18:30:00-04:00
End: 2025-05-15T19:30:00-04:00
Location: Tri-Town Youth Services

Participant First Name*

Participant Last Name*

Participant DOB

Please list any allergies participant has*

Which School does Participant attend?

Email*

Parent/Guardian First Name*

Parent/Guardian Last Name*

Parent/Guardian Email*

Phone

Name of individual picking up participant*

Emergency Contact Phone Number*

Emergency Contact Name*

I grant Tri-Town Youth Services permission to use my/my child’s image in photos or videos for promotional, educational, and outreach purposes, including print, digital, and social media. I understand no compensation will be provided, and I release Tri-Town Youth Services from any liability related to image use.*

Yes

No

Mom and Me Night Out

May 15 @ 6:30 PM - 7:30 PM

Sorry, This Event is Full.

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