MY GYM Children's Fitness Center

PARENTS' NIGHT OUT Pre-Registration Form
Fourth Friday or every month, 6:00 pm - 9:00 pm
Fee: $30.00 ($25.00 for additional siblings)


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:

First Child Information:
First Name:
Date of Birth:
Any Alergies?
Register Additional Child? Yes No

Please select desired day(s):

Friday, September 26th

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

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.