FALL 2008 Registration
CHECK THIS BOX if you only want to sign up for the Wacky Fun Friday Dance Party!
READY TO REGISTER? Just fill out the form below, submit
your payment information, and your child is set!
Please remember to complete one form per child.
Child's Name *
Parent/Guardian First Name *
Parent/Guardian Last Name *
Parent Authorized *
to Pick-Up Name
Address *
Address Line 2
City *
State *
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Micronesia
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Zip Code *
Home Phone *
Work Phone
Email Address
Emergency Contact Name *
Emergency Contact Phone *
Grade *
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Teacher *
BE COOL BEFORE SCHOOL
-- Select Number of Days --
One Day
Two Days
Three Days
Four Days
Five Days
Monday
Tuesday
Wednesday
Thursday
Friday
5:00 PM Pick-Up
6:00 PM Pick-Up
One Day,
($360 total sesssion)
Two Day,
($720 total sesssion)
Three Day,
($1020 total sesssion)
Four Day,
($1360 total sesssion)
Five Day,
($1600 total sesssion)
One Day,
($400 total sesssion)
Two Day,
($800 total sesssion)
Three Day,
($1140 total sesssion)
Four Day,
($1520 total sesssion)
Five Day,
($1800 total sesssion)
Late Pick-Up
One Day,
($440 total sesssion)
Two Day,
($880 total sesssion)
Three Day,
($1260 total sesssion)
Four Day,
($1680 total sesssion)
Five Day,
($2000 total sesssion)
COURSE REGISTRATION
Day of Week
Monday
Tuesday
Wednesday
Thursday
Friday
Class Description
Day of Week
Monday
Tuesday
Wednesday
Thursday
Friday
Class Description
Day of Week
Monday
Tuesday
Wednesday
Thursday
Friday
Class Description
Day of Week
Monday
Tuesday
Wednesday
Thursday
Friday
Class Description
Day of Week
Monday
Tuesday
Wednesday
Thursday
Friday
Class Description
Wacky Fun Friday
($12.00 After School Program not registered on Fridays)
Total Sessions:
Registration Fees:
Total Amount Due:
WHAT SIZE WOULD YOU LIKE FOR YOUR FREE T-SHIRT?
Medium (5-6)
Large (7-8)
Extra Large (10-12)
Wacky Fun Friday
($22.00 Non-Participants of After School program)
Registration Fees:
Total Amount Due:
PAYMENT INFORMATION
Same as above
Name on Credit Card
first
last
Billing Address
Billing Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Micronesia
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Zip Code
Credit Card Type
Credit Card Number
Expires
January
February
March
April
May
June
July
August
September
October
November
December
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
MEDICAL INFORMATION AND AGREEMENT
Please describe any physical conditions, allergies or limitations your child has:
Doctor *
Doctor's Phone *
* By checking this box, I understand that only those listed above will be allowed to pick up my child, and I've made sure to list all people who have my permission. I have read the rules regarding the after school program and agree to follow them. I understand that there will be no refunds after February 28, 2008 and that repeated late pick-ups (three ocurrences) will cause dismissal from the program.