Afronaut Club Registration Form

Afronaut Club Registration Form

To Register Please Complete All Questions.
Parents Information *

First Name Last Name
Address *

Street Address/PO Box

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Phone Number *

Area Code Phone Number
Cost:

$40 per family for 1 Year
How Many Children are you enrolling? (If '0' skip the next page) *

Children Information
Child 1 Name

First Name Last Name
Date of Birth

Month Day Year
Email (If any)
example@example.com
Child 1 Age
Child 2 Name

First Name Last Name
Date of Birth

Month Day Year
Child 2 Age
Email (If any)
example@example.com
Child 3 Name

First Name Last Name
Date of Birth

Month Day Year
Child 3 Age
Email (If any)
example@example.com
Child 4 Name

First Name Last Name
Date of Birth

Month Day Year
Child 4 Age
Email (If any)
example@example.com
Child 5 Name

First Name Last Name
Date of Birth

Month Day Year
Child 5 Age
Email (If any)
example@example.com
Child 6 Name

First Name Last Name
Date of Birth

Month Day Year
Child 6 Age
Email (If any)
example@example.com
Child 7 Name

First Name Last Name
Date of Birth

Month Day Year
Child 7 Age
Email (If any)
example@example.com
Child 8 Name

First Name Last Name
Date of Birth

Month Day Year
Child 8 Age
Email (If any)
example@example.com
Child 9 Name

First Name Last Name
Date of Birth

Month Day Year
Child 9 Age
Email (If any)
example@example.com

Check Payment Option *
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The Afronaut Club Membership ( $ 40.00 for each year )
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