CHILD’S  NAME__________________________________________AGE_____

                             ______________________________________________

CLASS LOCATION______________________________DAY________TIME_______        

PARENT’S NAME______________________________________________

ADDRESS____________________________________________________

CITY__________________________________STATE______ZIP_________

PHONE#______________________CELL PHONE#______________________

E-mail_______________________________________________

Are there any pertinent medical conditions that we should be aware of?

No_____ Yes_____

If yes, please explain______________________________________________

_____________________________________________________________

Participation in any physical activity may involve risk of injury.  As a parent, guardian or participant, I am aware of these hazards and my ability to participate.  I understand that Kathye Flanagan may not be held legally responsible for any injuries or accidents that may occur.

SIGNATURE_____________________________________DATE____________

FEE IS $85.00 PER CHILD PAYABLE ON THE FIRST DAY OF CLASS.

FAMILY  DISCOUNT  AVAILABLE.   ENROLLMENT FEE IS NONREFUNDABLE.

              MAKE CHECKS PAYABLE TO KATHYE FLANAGAN.

PAID_______________  CASH_____________ CHECK#____________