Adult Child Program Sign Up Form

Child's First Name*

Child's Last Name*

Child's Date of Birth*

Parent/Guardian First Name*

Parent/Guardian Last Name*

Email*

Name of Adult Accompanying Child to Class*

Does your child have any dietary restrictions or allergies*

Please explain your child's dietary allergy or restriction

Please select your program(s)*

Amount$0.00

Payment Method:*

Payment Notes/Additional Info:

Name on Card:*

Email You Want Associated with Credit Card Payment:*

Card Number:*

Card Exp Month / Year:* /

Card CVV:*

Card Billing Zip:*