Registration

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Join us Dec. 20th from 6-9 PM for a fun night of games, food, and tumble! Parents, this is a great way to get that last minute shopping done before Christmas. Pizza, cookies, and tumble class are included in the fee.

Event:

Start Date/Time:

End Date/Time:

Fee per Student:

Room:

* - denotes required fields

Family Information

	First Name:*	Last Name: *
	Type*
	Home Phone:	Cell #: Work #:
	Email:*	(Emails are kept confidential)

	Address: *
	City: *	State: * Zip: *
	Emergency Contact Info*

Students entered below will be added to your family's account

Add New Student #1:

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	Student's First Name: *	Last Name: *
	Student Gender:	Birth Date: * (format=mm/dd/yyyy)
	Student Email:
	School:	23-24 Grade Level:*
	Disabilities (Leave blank if NONE):
	Allergies (Leave blank if NONE):
	Medications (Leave blank if NONE):

Questions/Options:


Does your child have any food allergies?

Additional Information:

Payment

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I've read the above and agree.

Release of Liability

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I've read the above and agree.

Photo/Video Release

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I've read the above and agree.

Enter your Full Name:

Other Questions/Comments:

Credit Card Verification:

Card Number:

Name as it appears on card:

Nickname:

Card Expiration Month:

Exp Year:

Address Line 1:

Address Line 2:

City:

State: Zip:

eCheck/Bank Draft:

Bank Name:

Bank Routing Number:

(9-digit number)

Your Account Name:

(Your name on your bank statement)

Your Account Type:

Account Number: