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Marriage Connections Date Night on Sunday, September 22, 2024 @ 6:00 PM

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**Please read this carefully**

Please only register once as a couple. There are two payment options. Both options include all seven date nights. Payment option 1: If you do not need childcare, please click on the $70 "no childcare" option. Payment option 2: If you need childcare, please click on the $100 "childcare included" option. Childcare is available for ages Birth through 5th grade. Please register your child(ren) as space is limited and not guaranteed. Once we reach capacity for childcare, a waitlist will become available, and we will do our best to accommodate your childcare needs.

**If your children are registered for childcare, and can't make it, please contact Carly Gomez at cgomez@wacc.net or call 562-945-4500 x115 to let us know. We want to accommodate as many families as possible, and this will allow us to contact families on the waitlist.  
170.00 
1100.00 
Please complete the fields below with ADDITIONAL INFORMATION:
*Spouse's First Name :
*Spouse's Last Name:
*Email Address :
*Phone Number :
*Will you need childcare for one or more children? :
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If you answered "NO" to childcare, please skip to the end of this form.
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If you answered "YES" to childcare, please fill out the following questions only about the children you NEED childcare for and be sure to add the childcare fee at the beginning of this form.
Child 1 - First and Last Name:
Child 1 - Birthday (MM/DD/YYYY):
Is Child 1 fully potty trained?:
Child 1 - Special Instructions (including allergies, medications, special needs):
Child 2 - First and Last Name:
Child 2 - Birthday (MM/DD/YYYY):
Is Child 2 fully potty trained?:
Child 2 - Special Instructions (including allergies, medications, special needs):
Child 3 - First and Last Name:
Child 3 - Birthday (MM/DD/YYY):
Is Child 3 fully potty trained?:
Child 3 - Special Instructions (including allergies, medications, special needs):
Child 4 - First and Last Name:
Child 4 - Birthday (MM/DD/YYYY):
Is Child 4 fully potty trained?:
Child 4 - Special Instructions (including allergies, medications, special needs):
*I understand that if I need childcare, I must register my children on this form:
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