Clarkdale Fall 2024 Club Enrollment
Mondays, 2:45-3:45- Afterpay available on this form
Camper's Information
Student Name
First Name
Last Name
Teacher Name
Age
Grade (Enter 0 for Kindergarten)
Gender
Please Select
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Uniform Size
YXS
YS
YM
YL
YXL
AS
AM
AL
AXL
Student Photo (Optional)
Browse Files
Cancel
of
Parent/Guardian Information
The parents/guardian listed below will be the authorized person to pick-up the child after the class.
The parents/guardian listed below will also be the primary emergency contact person.
Name
First Name
Last Name
Relation
Phone Number
-
Area Code
Phone Number
Picture upload
Browse Files
Cancel
of
Name
First Name
Last Name
Relation
Phone Number
-
Area Code
Phone Number
Picture upload
Browse Files
Cancel
of
After Club
ASP
CAR
People permitted to pick up your child from Cheer Club
Medical Information
Does the child have any allergies? If yes, please list them below:
Does the child have any previous injuries? If yes, please explain them below:
Does the child have any current medical conditions? If yes, please list them below:
Does the child takes any medication? If yes, please list them below and explain its purpose:
Authorization
I, the parent/guardian of this camper gives authority to the staff of this camp to apply judgment in regards to medical assistance in the event of an accident, injury, or illness if the emergency contact person cannot be reached. I authorized first aid, medical/surgical diagnosis, and treatment which may deem necessary.
I released the organizers, coaches, staff, or managers of this camp for any responsibility in case of accident, illness, or injury during my child's enrollment.
Payments are inelgible for refunds however if your student is unable to participate for any reason including but not limited to; injury, school closings, sickness, scheduling issues, etc a class credit will be given out that can be used anytime within 1 calendar year.
I confirm that all information given in this form is true, complete, and accurate.
Parent/Guardian Signature
Payment Details
My Products
prev
next
( X )
New Student
$
225.00
Needs Uniform
Returning Student
$
199.00
Has Uniform
Enter coupon
Apply
Subtotal
$
0.00
Tax
$
0.00
Total
$
0.00
Payment Methods
Credit Card
Afterpay
After submitting the form, you will be redirected to Afterpay to complete the payment.
Submit
Print Form
Should be Empty: