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Assessment Clinics: May 19, 2025 5:00-6:30 pm May 20, 2025 5:30-7:00 pm Evaluations: Level 1: May 21, 2025 5:30-7:30 pm Level 2+: May 22, 2025 5:30-7:30 pm Makeup Evaluations: May 23, 2025 5:30-7:30 pm
Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Type
*
Caregiver
Father
Guardian
Mother
Parent
Self
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
*
State:
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NE
NC
ND
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
*
Students entered below will be added to your family's account
Add New Student #1:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (type none if none):
*
Medications (type none if none):
*
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (type none if none):
*
Medications (type none if none):
*
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (type none if none):
*
Medications (type none if none):
*
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (type none if none):
*
Medications (type none if none):
*
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (type none if none):
*
Medications (type none if none):
*
Questions/Options:
Are you interested in Elite, Prep or Novice?
*
Which level are you interested in?
*
Are there any special circumstances we need to know prior to evaluations?
*
Additional Information:
Other Questions/Comments:
Credit Card Verification:
Card Number:
*
Visa
Mastercard
Amex
Discover
Name as it appears on card:
*
Nickname:
Card Expiration Month:
*
01
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08
09
10
11
12
Exp Year:
*
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
2055
Address Line 1:
Address Line 2:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
VI
Zip:
*
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