PeeWee P.E - Registration

School/Facility Name:

1 Child's Name:	Date of Birth:	Age:
2 Child's Name:	Date of Birth:	Age:
3 Child's Name:	Date of Birth:	Age:

Address:
City:	State:	Zip Code:
Daytime Phone #:	Cell Phone #:
Parents/Guardians:	Email:

Emergency Contact Name

Phone

Classes:
	First Child (Monthly Fees are $20.00 per month)
	(Additional Children are given a 10% discount)
	Additional Children
	Additional Children
=
	Total Monthly Fees

Name: (as it appears on card)
Card Number		Expiration Date		CVC#

PARENT OR GUARDIAN CONSENT:

I hereby give consent for my child to participate in the program. I certify that I know of no physical problems or conditions which would impair my child from participating in the program. If necessary, I authorize the persons in charge to secure first aid and/or the services of any legally qualified physician or hospital, and agree to assume all financial obligations connected therewith.

Parents Signature

Date