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Class Registration Form - Early childhood 2019

Membership Number (If applicable)
Participant Name*
Date of Birth* (mm/dd/yy)
Enrolled In
 ECD

 

Class/Program 1


 

Class/Program 1

 

Class/Program 2


 

Class/Program 2 (optional)

 

Contact Information


 

Address*
Address2
City*:
State
Zip
Email*
Cellular*
Home Phone
Work Phone

 

Parent / Guardian Information


 

Parent / Guardian Name
Parent / Guardian Phone

 

THESE DEPARTMENTS REQUIRE SEPARATE REGISTRATION. PLEASE CONTACT THEM DIRECTLY

Danny Berry Baseball x241, Martial Arts x276, Miami Children’s Theater x400, Miami Select Volleyball, 786.325.4063

 

Payment


 

Total Payment
Card
Name on Card
Number
CVV
Expiration

11155 SW 112 Avenue, Miami FL 33176
305.271.9000

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