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 fee is $10 for 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.