Military Parents Night Out Registration Form Page 2
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2Special Needs Information Form
Our Military Parent Night Out is for 6 weeks to 11 years old. We are on the move through out the
duration of the evening from the gym, to pool, to group activities.
Please take the time when you are signing in to alert our supervisor and staff about any special health
needs your child may require during the evening. We want to ensure that your child’s safety and medical
needs are met.
If your child requires medication and has the dosage before arriving at our program, are there any side
effects we need to be made aware of? YES / NO
(If YES please explain)
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If you circled Yes to: Does your child require special attention, medicine or a routine?
Please describe the special health care needs of this child and the plan of care as identified by the parent
and the child’s health care provider.
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Other concerns or information our supervisor and staff should be aware of:
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