Registration
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50 Candy filled eggs to be delivered to your house and ready for Easter morning!
Event:
Start Date/Time:
End Date/Time:
Fee per Family:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
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Type
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Adult Student
Father
Grandparent
Mother
Other
Parent
Parent/Guardian
Step Father
Step Mother
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
*
State:
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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
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UT
VA
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WA
WI
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Zip:
*
Emergency Contact(s) Name / Phone
Add New Student #1:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Special Needs / Disabilites:
Allergies (Leave blank if NONE):
Allergies / Medications:
Doctor / Phone:
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Special Needs / Disabilites:
Allergies (Leave blank if NONE):
Allergies / Medications:
Doctor / Phone:
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Special Needs / Disabilites:
Allergies (Leave blank if NONE):
Allergies / Medications:
Doctor / Phone:
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Special Needs / Disabilites:
Allergies (Leave blank if NONE):
Allergies / Medications:
Doctor / Phone:
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Special Needs / Disabilites:
Allergies (Leave blank if NONE):
Allergies / Medications:
Doctor / Phone:
Questions/Options:
Animals on premise?
*
How many children? Ages of children
*
Would you like your eggs hidden in backyard or front yard?
*
Additional Information:
Notice
(Show-Hide Details)
By registering for this event I am giving my permission for Fusion Gymnastics/East Coast Allstars to be on my property to hide said eggs. If I am placing the order for someone else by checking this box I agree I have informed the home owner Fusion/East Coast will be on their property.
I've read the above and agree.
Enter your Full Name:
*
Other Questions/Comments:
Credit Card Verification:
Card Number:
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Visa
Mastercard
Amex
Discover
Name as it appears on card:
*
Nickname:
Card Expiration Month:
*
01
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Exp Year:
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2024
2025
2026
2027
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2029
2030
2031
2032
2033
2034
2035
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2038
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2046
2047
2048
2049
2050
2051
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2053
2054
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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