1. Name:_____________________

2. Age:_______

3. Date of birth:_______

4. Address:_____________________________________________________

5. telephone:______________

6. Male_______ Female________

7. Emergency contact name:______________________________________

8. Emergency contact telephone:___________________

Fees:
1) Mondays $30.00 +1.96 tax = $31.96
2) Sunday and/or regular nights $60.00 +4.20 tax = $64.20