Street     

City          State          Zip    

Phone Number    

Please name ALL children in your family.

          Child's Name                                   Age                             Birth Date
                                      

Please select the session that you would like to attend by marking 1st, or 2nd choice.

1st 2nd Tuesday 9:45 am          1st 2nd Wednesday 9:45 am          

If we are unable to enroll you in your first choice, we will enroll you in your 2nd choice
accordingly.  Families accepted into the winter 2010 program will be notified by mail as to which
session they have been enrolled.

First session of Kidz Gym starts the week of January 24th.

          I agree to follow the guidelines of the Kidz Gym program.  I will be responsible for my
child's safety at all times and insure that he/she does not jeopardize the fun and safety of
other children.
          I will attend weekly, except for illness or out-of-town family events.

                                                    Signed    

                                                    Email Address: