Child's Name *

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name

Phone

(###)

###

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For Which Days are You Registering? *

There are two clinics, please pick just one.

1 Day ($40) in June (11th or 12th)

The Full June Clinic ($60) June 11th and 12th

Both Clinics ($110)

1 Day ($40) in July 9th or 10th

The Full July Clinic ($60) July 9th and 10th

Emergency Contact Name

First Name

Last Name