Tiny Trailblazers Registration
Please complete this form. If you are not a member, please also complete the waiver and media release on the next page.
Caregiver Name
*
First Name
Middle Name
Last Name
Child #1 Name
*
First Name
Middle Name
Last Name
Child age
*
18 months-5 years old
Child #2 Name
First Name
Middle Name
Last Name
Child age
18 months-5 years old
Caregiver E-mail
*
Phone Number
*
-
Area Code
Phone Number
Please enter your insurance provider information:
Insurance Information is required.
Who is your Insurance Provider?
*
Required Field
What is your Policy Number?
*
Required Field
Anything you wish to share about your child(ren)?
*TRAK welcomes children of all abilities.
Select your Class!
TINY T's 5 WEEK SESSION (TUESDAY CLASS Starting September 13th)
TINY T's 5 WEEK SESSION (THURSDAY CLASS Starting September 15th)
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If you are NOT a current TRAK member, please also read and then sign the following waiver, required for all programs and tours of our property.
Names of all participants covered by this waiver:
*
This includes caregiver and child(ren).
Parental/Legal Guardian Name, Printed
*
Parent/Legal Guardian Signature
*
Clear
Date:
*
Media Release
I hereby grant or deny permission for photographs or video recording of myself or child(ren) to be used for promotional purposes:
Permission
*
Granted
Denied
Parent/Legal Guardian Signature:
*
Clear
Register Class
Should be Empty: