MY GYM Children's Fitness Center

WINTER BREAK CAMP Pre-Registration Form
Monday, December 20 - Friday, December 31, 2010 9 am - 12 Noon, 1 pm - 4 pm
Camp Fee: $30.00 each

Parent or Guardian Information: Please fill out the information below:

Your First Name:

Your Last Name:

Your Street Address:

City, State, Zip Code:

Your Email Address:

Home Phone Number:

Cell Phone Number:

Notes / Comments:

Returning Customers:

If you know that we have your recent Credit Card information on file and you would like us to use it for payment, please enter the last 4 digits of your credit card number and the 3-digit CVN number, found on the back of the card:

Last 4 digits:

CVN Number

First Child Information:

First Name:

Date of Birth:

Any Allergies?

Second Child Information: (Optional)

First Name:

Date of Birth:

Any Allergies?

Please make your choice(s) from the available remaining days:

December 2009

Monday

Tuesday

Wednesday

Thursday

NOTE: Submitting this PRE-REGISTRATION FORM does not automatically register your child.
We will contact you to finalize your registration on a "first come - first served" basis.
* Due to limited space, no refunds can be issued once the child is enrolled.