K-5 Youth Lounge Drop n Play Registration

For Newton Public School Families Only

Parent Name(Required)

First Last

Parent Email(Required)

Parent Phone(Required)

Student Name(Required)

First Last

Student Grade(Required)

Second Student Name

First Last

Second Student Grade

Emergency Contact 1 Name(Required)

First Last

Emergency Contact 1 Phone(Required)

Emergency Contact 2 Name(Required)

First Last

Emergency Contact 2 Phone(Required)

Allergies or food restrictions

K-5 Youth Lounge Drop n Play Registration Fee (Required)

Price: $18.00

Convenience Fee

Price: $0.00

Total

Payment Method(Required)

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name