Parent’s Name: _________________________________________________________

Address: __________________________City: __________State: ____Zip:___________

Phone: _____________________ Emergency Phone Number: _____________________

E-mail Address: _________________________________________________________

Age: __________________________          DOB: ___________________ mm/dd/yyyy

Does your child have any medical problems?      Yes          No

Please explain: __________________________________________________________

List all Medications: ______________________________________________________

Class Day: _________________________Class Time: ___________________________

Number of Classes:___________________ Start Date: ___________________________ 

I will notify LIC Kids of any changes in the medical condition of my child. By registering for programs at LIC Kids, I agree to follow all policies and procedures of the facility. I enroll understanding the risks and benefits of physical activity and state that all family members participating are in condition to play.

Registration fees are payable at the time of registration (one time $10 fee new members only). Personal checks are accepted. Please make checks payable to LIC Kids. Please note: there will be a $30 fee for returned checks. We will refund tuition for classes that have not occurred up until week 3 of the semester. After the 3rd week, we can issue a credit for future classes only. Discounts received are deducted from the refund. A $25 cancellation fee will apply.