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.
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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
*
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:
Media Permission
*
Granted
Denied
Parent/Legal Guardian Signature:
*
Are you a TRAK Member?
My Products
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Tiny T's Member Payment for One Child
$
98.15
Tiny T's NonMember Payment for One Child
$
123.89
Tiny T's Member Payment for Two Children
$
195.98
Tiny T's NonMember Payment for Two Children
$
247.48
Total
$
0.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Register Class
Should be Empty: