CVRC Client Intake Form for We Rock The Spectrum - Clovis
If you have any questions about this form or the services we provide, please call our CVRC Intake Coordinator at (559) 999-8341. Vendor # HC1908
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
No age limit for CVRC clients. Thursday afternoons are meant for the teens and adults.
UCI Number
*
Parent/Guardian Name(s)
*
First Name
Last Name
Parent's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent's Email Address
*
example@example.com
Services Requested
*
Please Select
$19 per person, open play single visit, max of 2 hours
$54 per person, Rock Bronze, 3 open play pack
$99 per person, Rock Silver, 6 open play pack
$189 per person, Rock Gold, 12 open play pack
$150 per person, Monthly membership, max of 2 hours per visit per day
Service code is 525. Sub Code is SRA. Single visits are ideal for those who live far away or just want to try it one time. Rock Bronze, Silver, and Gold is ideal for those who only plan to visit infrequently like once or twice a month. Monthly memberships are best for those who want to play everyday. Monthly members can play everyday as long as there is space available. Reserving a slot at werockclovis.com is recommended.
Potential Start Date
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Month
-
Day
Year
Date
CVRC Service Coordinator's Name
First Name
Last Name
Service Coordinator Phone Number
Service Coordinator Email
example@example.com
Save
Submit Intake
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