Soccer Shots Frederick Registration

You are registering for:
Wetherburne Park Program (Summer 2010-Thursdays 5:00pm-8 week program- Open to the Public)
Dates: 07/01/10 - 08/18/10 (5:00pm)
Price: $76.00

All fields are required unless otherwise noted.

Child Information

Name First Last
Birthdate MM/DD/YYYY
Gender
Special Needs
E.g. Allergies, Disabilities, etc.
Classroom Only if you know it.

Parent Information

Name First Last
Address
Use second line only if applicable.
City
State/Province
Zip/Postal Code
Phone
XXX-XXX-XXXX
Email Address
Used to send you a receipt and important updates.

Emergency Contact

Same as Above
Name First Last
Phone
XXX-XXX-XXXX

Important Stuff

I have read and agree to the Policies.
I have read and agree to the Waiver and Release.

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