2025 Clubhouse Registration Form

First NameMiddle NameLast Name

Latino/HispanicNon Latino/Hispanic

Authorized Pick-upWalker*

First NameMiddle NameLast Name

Latino/HispanicNon Latino/Hispanic

Authorized Pick-upWalker*

First NameMiddle NameLast Name

Latino/HispanicNon Latino/Hispanic

Authorized Pick-upWalker*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Format: (000) 000-0000.

Please enter a valid phone number.Format: (000) 000-0000.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Format: (000) 000-0000.

Please enter a valid phone number.Format: (000) 000-0000.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Fill out this form completely. Your child's safety depends on it.

Anyone, including parents who are authorized to pick a member up, must be included on the list.
If any individual's information is incomplete that person will NOT be allowed to pick up a member. NO EXCEPTIONS

Primary ContactEmergency ContactParent/GuardianAuthorized to Pick Up Member

Please enter a valid phone number.Format: (000) 000-0000.

Primary ContactEmergency ContactParent/GuardianAuthorized to Pick Up Member

Please enter a valid phone number.Format: (000) 000-0000.

Primary ContactEmergency ContactParent/GuardianAuthorized to Pick Up Member

Please enter a valid phone number.Format: (000) 000-0000.

Primary ContactEmergency ContactParent/GuardianAuthorized to Pick Up Member

Please enter a valid phone number.Format: (000) 000-0000.

MEMBER INFORMATION - 1st Child in Family