Non-member Program Registration Form
This form is ONLY for people who do not reside within PHRA that want to register for a PHRA program. Kindly complete this form and we will follow up within 2 business days by calling you to pay over the phone.
Title of the program you wish to register for
*
Participant Name
*
First Name
Last Name
Participant Date of Birth
*
-
Month
-
Day
Year
Date
Current Date
-
Month
-
Day
Year
Date
AGE
Participant Phone Number (if under 18, please use parent or guardian number)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Participant Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorized Pickup Name
*
First Name
Last Name
Emergency Contact 1
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact 2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Medical notes
Submit
Should be Empty: