REGISTRATION FORM

Child Name *

Child Name

First Name

Last Name

Child's Age: *

Parent/Guardian *

Parent/Guardian

First Name

Last Name

Email Address *

Cell Phone *

Cell Phone

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Waivers

Photo/Video Release *

Photo/Video Release - I understand that Professor Qwbli's will be taking pictures and/or video to use for marketing purposes only. Professor Qwbli's will not release the names of any participant, but may use their image for event promotional purposes.

I understand & Agree

I understand. Do not use my child's image.

Late Pick-Up Fee *

I understand that my child must be picked up by the specified time, plus a 15 minute grace period or a $25 Late Fee will be charged.

I understand

Emergency Contact

Should we not be able to contact the primary parent/guardian, whom should we contact in case of an emergency?

Emergency Contact *

Emergency Contact

First Name

Last Name

Cell Phone *

Cell Phone

(###)

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