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

All non-members must make an appointment to sign a guest waiver and pay in person. Email: charlotte.boswell@genesishealthclubs.com

What session would you prefer

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

Payment Information

You will receive an invoice by email, which will include a link to pay by credit card.

Signature

Clear Signature

I accept full responsibility for my use of any and all apparatus, appliances facility privilege or service whatsoever, owned and operated by this Club at my own risk and shall hold this Club, its shareholders, directors, officers, employees, representatives, and agents harmless from any and all loss, claim, injury, damage or liability sustained or incurred by me resulting therefrom. By completing this form you agree that we may communicate with you by phone, or by using electronic communications such as email and text messaging. Your information will not be sold by Genesis Health Clubs.

Today's Date / Time

Date

Time

Promotional Code (Optional)