Summer Programs Registration Form

Holley Family Village, Inc.
Family Week One

Ages: 9 - 16
Deaf, Hard of Hearing, or DeafBlind Child's Full Name*

First NameLast Name
Parent/Legal Guardian*

First NameLast Name
Child's Gender
Child's Date of Birth*

MonthDayYear
Deaf, Hard of Hearing or DeafBlind?*
Child's Accommodation *
Additional Family Members (First Name, Last Name, Age, and DHHDB, Hearing.)
Primary E-mail*
Email Correctness Check*
Primary Phone Number
Phone Type
Please read the required Legal Forms before you submit.

1. A release of liability

2. Code of Conduct

3. Image Waiver
By enrolling the Holley Family Village program, you are signing this Agreements of A release of liability, Code of Conduct, and Image Waiver electronically. You agree your electronic signature is the legal equivalent of your manual signature on these Agreements. *
How many child(ren)?*
How many parent(s)?*
Would you like to help us pay for the processing fee?*

YesNo
Total $ Amount
Calculation

Payment

USDDescription

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Holley Family Village, Inc.