Clinic Sign Up

Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Guardian Name *

First Name

Last Name

Primary Phone Number *

(###)

###

####

Secondary Guardian Name

First Name

Last Name

Secondary Phone Number

(###)

###

####

Clinic *

May Clinic - May 5, 12, 19, 23, 26, and 30th

N/A

Camp *

Camp I - June 19-22

Camp I1 - July 10-13

N/A