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Star-Mites October Holiday Program *GYMNASTICS *CHEERLEADING *FOAM PIT *12MTR TRAMPOLINE *NINJA RIG *TUMBLING *FUN & GAMES
Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Mother/Father/Career
Carer
Department
Father
Grandparent
Guardian
Mother
Nanny / Au Pair
Other / Accounts
Parent
Self
Step Parent
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
*
State/Prov:
*
Postal Code:
*
Emergency Contact Info (Not Contact #1 or #2)
Students entered below will be added to your family's account
Add New Student #1:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non Binary
Birth Date:
*
(format=dd/mm/yyyy)
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Photo permission (Y/N)?:
*
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non Binary
Birth Date:
*
(format=dd/mm/yyyy)
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Photo permission (Y/N)?:
*
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non Binary
Birth Date:
*
(format=dd/mm/yyyy)
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Photo permission (Y/N)?:
*
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non Binary
Birth Date:
*
(format=dd/mm/yyyy)
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Photo permission (Y/N)?:
*
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non Binary
Birth Date:
*
(format=dd/mm/yyyy)
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Photo permission (Y/N)?:
*
Additional Information:
Other Questions/Comments:
Credit Card Verification:
Card Number:
Visa
Mastercard
Name as it appears on card:
Nickname:
Card Expiration Month:
01
02
03
04
05
06
07
08
09
10
11
12
Exp Year:
2024
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
Address Line 1:
Address Line 2:
City:
State/Prov:
Postal Code:
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