Monthly Gym Membership
Date
-
Month
-
Day
Year
Date is auto Populated
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Information
Students First and Last Name
Students First
Students Last
Student Goes By
Students Cell
Please enter a valid phone number.
Students Email
example@example.com
Student Grade
2021-2022 School Year
Student School
2021-2022 School Year
Student Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
T-shirts
Choose carefully. Your child will be issued the size selected. Exchanges are not guaranteed.
Student T-Shirt Size
Please Select
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult XXL
Choose carefully. Your child will be issued the size selected. Exchanges are not guaranteed.
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Parent/Guardian Information
Parent/Guardian One
Name
First Name
Last Name
Primary Contact Phone Number
Please enter a valid phone number.
Primary Email Contact
example@example.com
Relationship to Student
Father
Mother
Other
Parent/Guardian Two (Optional):
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to Student
Father
Mother
Other
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Emergency Contact (Other than parent)
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship to Minor
Allergies, Reactions or Other Comments
Please provide and information about Allergies, Reactions or Other Comments
By checking this box, I certify that I have read and understand the contents of the COVID-19 Consent and Liability Waiver. I understand that in checking this box, I am giving my electronic signature and that I have the authority to make this decision on behalf of the above listed child. I also authorize Catholic High school to use my child's photograph or video image for publicity purposes, and I understand there is no remuneration attached to the use therefor. I agree and understand that by registering my child for this program, I am authorizing Catholic High School to bill me $100 per month plus any fees related to these monthly transactions.
*
Agree
Disagree
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Membership
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Monthly Gym Membership
Monthly Recurring Gym Membership
$
100.00
for each
month
Email
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: