Lazy Larry Club Membership Online Registration Form

Lazy Larry Loves to Learn Membership Registration

Complete the form below to sign up for our membership service.

Student

First NameLast Name

School

Parent

First NameLast Name

Registration Date

Date

Student's Date of Birth

Date

Email Address

example@example.com

Student's National Insurance No.

Parent's Phone Number (cell)

Format: (000) 000-0000.

Parent/Guardian (Emergency Contact)

Address

Street Address

Street Address Line 2

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Postal / Zip Code

Country

Where did you hear about us?

1. Membership is available to anyone 7 years of age or older.

2.As a member you promise NOT to misuse products and services, act in a manner of

misconduct or any fraudulent or business activity at any time.

3. Membership packages are effective immediately and will expire on the last day of the third month of purchase. At this time you can reactivate your membership by simply reapplying at the Lazy Larry Loves to Learn location.

4. Your membership is none refundable and may not be transfered. Your membership is limited to the services labeled in your package.

5.Lazy Larry Loves to Learn reserves the right to discontinue any membership due to misuse of products and services at anytime

Your information is kept private and is utilized only for the purposes of processing applications at the request of the applicant.

Your email will be entered into our database to inform you of upcoming events and promotions.

We aim to partner with you and we want you to be comfortable with our products and

services.

Once you submit your application, we will contact you shortly to complete your membership application.

Additionally, you will need a Copy of the students government issued photo identification, national insurance card and immunization card (must be submitted).

Thank you!

Select one of the following membership packages

Does your child suffer from any medical illness or allergies?

If You answered yes for the above question, please give specific details.

Signature