Youth S&C Program

4 week - Youth Strength & Conditioning Program 2021

MOMENTUM FITNESS WARRNAMBOOL
The Program will run for 4 weeks with 3 x 60min session at a cost of $190.

We will require a non refundable deposit of $50.00 to secure your childs spot and the rest will need to be paid by the 1st of January 2021

Name of Child Participationg *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Email address *
Date of Birth *

Day Month Year
Age *
Height
Weight
Emergency Contact Person/Parent or Guardian:
Name *

First Name Last Name
Phone Number *

Is you child currently under a Doctor/Physicians Care? *

Yes No
If Yes, please fill out all relevant details.
Physicians Specialty
Does this hinder him/her from performing any kind of excercise?

Yes No
Doctor or Physicians Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

24/7 Disclaimer and T&C's

Please read this carefully and sign and date if you agree to the T&C's outlined below
Signed by Parent or Guardian *

Clear
Date *
Choose one of the options below
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Pay in Full $ 190.00 AUD

Just pay Deposit $ 50.00 AUD

Total $ 0.00 AUD

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

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