Clinic Registration Form
Please fill in the form below.
Name
First Name
Last Name
Age if minor
Parent/Guardian if minor
Contact Number
*
E-mail
*
Personal Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Clinic Goals
Please tell us a little bit about what you would like to accomplish in this clinic
Please check which clinics you would like to register
*
August 16 Obstacle Course Clinic $60
July 22-23 Liberty Clinic with Allison Whisler $300. Lunch and snack provided.
Date
-
Month
-
Day
Year
Date
Type a question
My Products
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( X )
Obstacle Clinic
$
60.00
Quantity
1
2
3
4
5
6
Liberty Clinic with Allison Whisler
$
300.00
Quantity
1
2
3
4
Stall per night
$
25.00
If attending both clinics; add stall for each. Limited stalls; check availability
Quantity
1
2
3
4
5
6
Turnout
$
20.00
If attending both clinics; add turnout for each
Quantity
1
2
RV Hookup per night
$
10.00
If attending both clinics; add RV hookup for each
Quantity
1
2
3
4
5
6
Auditor with Lunch
$
35.00
Quantity
1
2
3
4
5
6
7
8
9
10
Subtotal
$
0.00
Tax
$
0.00
Total
$
0.00
Submit
Payment Methods
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and
submit
the form.
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