Mommy and Me Group Lessons

Childs Name *

First

Last

Childs Date of birth

Age

Gender

Male
Female

Address

Address Line 1

Address Line 2

City

State

Zip Code

Parents/Guardians Name

Are you an employee?

Yes
No

Cell

Emergency Contact Name

Emergency Contact Number

Email *

Member

$185.00
I'm a non-member

Non - Member

$225
I'm a member

What session would you prefer

All classes would be at 11:45am (Monday - Thursday)

How would you like to pay (We will reach out for payment after form has been submitted)

PAC Account **Preferred**
Check (Check must be brought in to hold spot) | Must be paid in 48 hours to hold
Cash | Must be paid in 48 hours to hold
Credit Card | Must be paid in 48 hours to hold

Signature

Clear Signature

Waiver | I accept full responsibility for my use of any apparatus, appliances, facility privileges, or service whatsoever, owned and operated by this club, directors, officers, employees, representatives, and agents harmless from any loss, claim, injury, damage or liability sustained or incurred by myself, my family or others under my supervision or control resulting therefrom. Also, I agree that the information above is accurate and complete. I also understand and acknowledge that photos/videos may be taken for publicity/marketing purposes. I also give my authorization for any photos or video footage of myself or my minor child to be used in this fashion.

Today's Date / Time

Date

Time

Promotional Code (Optional)