Child Name I: _____________________________________ DOB: ________
Child Name II: ______________________________________ DOB: ________
Moms Name: _____________________________________
Dads Name: _____________________________________
Telephone: (Home)________________ (Work)________________ (Other)_________________
Address: _________________________ City:________________ Zip:__________
E-Mail Address: _____________________________________
4 Week or 7 Week Program: ____________________ Amount Paid: $_______ Date: _______
Payment due upon registration. Make checks payable to Quarry Hill Club.
MC/VISA Card Number: _________________________ Exp:________________
