Membership Form
Youth Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School
Grade Level
*
T-shirt Size
*
Small
Medium
Large
X-Large
Insurance Provider Name
*
Medical Insurance #
*
Does the child have any allergies?
*
Does the child have any medical conditions that we should be aware of?
*
Parent/Guardian Information
Mother's Name
*
First Name
Last Name
Father's Name
*
First Name
Last Name
Mother's Phone Number
*
Please enter a valid phone number.
Father's Phone Number
*
Please enter a valid phone number.
Mother's Email Address
*
Father's Email Address
*
Emergency Contact
*
List first name, last name and phone number
Payment Details
Payment Method
*
Please Select
Credit Card
CashApp
Annual Fees
*
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( X )
Membership Fee (non-refundable)
Annual fee per one child in the immediate family
$
125.00
Additional Children (non-refundable)
Annual fee per additional sibling not relative or friends
$
80.00
Quantity
1
2
3
4
5
6
7
8
9
10
Donation
optional
$
25.00
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card
Acknowledgment
I agree to follow the guidelines, rules, and policies of the SHINE organization.
Membership fees are for children within
one
household. Additional children are for siblings
not
relatives and friends. All fees are non-refundable.
I allow my child to be photographed or be part of the video that will be used for marketing, promotion, and advertisements.
Bad behavior will
not
be tolerated. A repeated offense of the youth may result in suspension or discharge from the organization permenantly.
Parent/Guardian registered in this form has legal custody over the child.
I allow my child to ride any vehicle that is related to the group's activities provided that there's an adult on board.
For medical emergencies, I allow the medical team of this organization to take care of my child.
I release this organization from any and all liability from accident or injury to the child during the SHINE organization related events.
Parent/Guardian Signature
*
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: