Register today classes start at $20.00 per month

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