INSTRUCTOR PASTOR PETE HOPKINS

UPSIDE DOWN COMMUNITY YOUTH CENTER

PARTICIPANT NAME:_________________________________________________

ADDRESS:__________________________________________________________

PHONE NUMBER:________________ EMAIL:______________________________

PARENT/GUARDIAN (if under 18):_______________________________________

PHONE (IF DIFFERENT FROM PARTICIPANT):_______________________________

EMERGENCY CONTACT:  

NAME:_________________________________PHONE:_____________________

RELATIONSHIP:____________________________________________________

•  ALL PARTICIPANTS MUST HAVE A LIABILITY WAIVERS FILLED OUT AND SIGNED BY PARTICIPANT OR PARENT/GUARDIAN

•  REGISTRATION FEE IS NON-REFUNDABLE-$10

•  MONTHLY FEE ARE PAYABLE BY THE 1ST OF EACH MONTH-$10

•  NO LONG-TERM COMMITMENT, CAN STOP AT ANY TIME

•  PARTICIPANTS 10 AND UNDER MUST BE ACCOMPANIED BY AN ADULT (ADULT DOES NOT HAVE TO PARTICIPATE)

SIGNATURE AND DATE:____________________________________________________________