Visits can be used for any of our Saturday Night Open Gym. One visit per child. Age Restrictions do apply, see website for most up to date schedules. (Date on registration does not correlate to specific session, it is only used to put on events calendar)
Start Date/Time: End Date/Time:
Fee per Family: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
Home Phone:* Cell #: Work #:
Email:* (Emails are kept confidential)
Address: *
City: * State: * Zip: *
Emergency Contact Info (other than parent)*
Other individuals authorized to use card ? Skip if none
If this is a gift what name would you like it under?
Additional Information:
Assumption of Risk / Release of Liability
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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: *
Card Expiration Month: *   Exp Year: *
Address Line 1: Address Line 2:
City: State: Zip:*