REGISTRATION FORM
Please Mail or Fax to 386-822-7502
(Printable Registration Form)
Today's Date _____________
Child's Name__________________________________________ DOB ___/___/___
Grade (next fall) ______ M / F School ______________________________
2nd Child's Name_________________________________________ DOB ___/___/___
Grade (next fall) ______ M / F School _____________________________
Address___________________________________ City ______________ Zip _______
Day Phone (______)_________________ Night Phone (______)______________
Cell/ Pager (______)_________________ E-mail____________________________
If Possible, Please Group Me with the Following Friends:
1)____________________________________ , 2)__________________________________
| Fees | ||||
| Week 1 | Start Date: ______________________ | $249 | ||
| Extended Care (Choose and Circle) | AM ($30) | PM ($40) | ||
| Week 2 | Start Date: ______________________ | $249 | ||
| Extended Care (Choose and Circle) | AM ($30) | PM ($40) | ||
| Week 3 | Start Date: ______________________ | $249 | ||
| Extended Care (Choose and Circle) | AM ($30) | PM ($40) | ||
| Week 4 | Start Date: ______________________ | $249 | ||
| Extended Care (Choose and Circle) | AM ($30) | PM ($40) | ||
| Total |
|
Payment Method: |
___ Check or Money Order |
___ MasterCard |
___ Visa |
|
Card Number:_____________________________________ |
Expiration Date:_______________ |
||
|
Name as it Appears on Card:___________________________ |
Security Code________________ |
||
|
Signature:_____________________________________________Amount to be Billed:$__________
|
|||
SHIRT SIZE YOUTH SIZES SM MED LARGE XL
The Volusia County School Board is not affiliated with the event in any manner, nor does it endorse or assume any responsibility for any activities, which may occur in connection with it.