PROGRAM REGISTRATION

Participant’s First Name
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Participant’s Last Name
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Date of Birth (mm/dd/yyyy)
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Parents name


(If participant is under the age of 18)
Address
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City
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State
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Zip
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Primary Phone
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Email
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Emergency Contact
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Emergency Contact Phone
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Membership Status – Participant is a
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MemberChild of MemberNon-Member
Programs
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28 Day ChallengeAfter School ProgramBallet & Tumbling ClassDance Jam 4 KidsEast Coast Panthers Summer Basketball CampGRITJr. Ballerz BaseballJr. Ballerz BasketballJr. Ballerz Football Quarterback/Wide Receiver ClassJr. Ballerz Pre-SportsJr. Racquetball Group LessonsJumpin’ & Jivin’Junior TennisKicking Bettas JuniorKicking Bettas SeniorKid’s Hip Hop & Dance Movement Class Ages 4-6Lifeguard TrainingLittle YogisMaster’s Competitive Swim TeamParent & Child Swimming LessonsPrivate Swim Lessons for Adults & ChildrenRacquetball LeagueSmall Group TrainingSummer Co-Ed Sand Volleyball LeagueSummer Single Racquetball ProgramSummer Youth Sports CampYouth Basketball ClinicYouth Basketball ExperienceYouth Swimming LessonsZumba Kids
Payment Method
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Credit Card
Check
Member House Charge
PAC Gift Card

Disclaimer

I hereby waive and release rights/claims for damages I may have against the Premier Athletic Club and its employees, and all injuries that may be suffered in connection with participation in any of the Premier Athletic Club programs.
Signature
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(Signature of parent or legal guardian if participant is under 18 years of age)
Date (mm/dd/yyyy)




If you are human, leave this field blank.