Registration

Registration

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Event:

Start Date/Time:

End Date/Time:

Fee per Family:

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*

Questions/Options:


How much would you like to donate to the Kendall Pickering Ripple Effect Scholarship?*
Every $100 donation comes with a free Kendall Pickering Ripple Effect Scholarship t-shirt. Please list your shirt(s) sizes.

Additional Information:

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: