Radik's Youth Fishing Club Registration

Radik's Youth Fishing Club Registration
Childs Information
Name

First NameLast Name
Birth Date

MonthDayYear
Grade
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Youth T-shirt Size
Parent/Guardian Information
Name

First NameLast Name
Home Number
Format: (000) 000-0000.
Cell Number
Format: (000) 000-0000.
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Please send $75 Payment via Cash App to $Radik5

Cash/Check will be accepted within 3 days of registration if needed
Should be Empty: