Re-enrollment form for membership in girls co-op

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Co-op applying for *

Peach Blossoms
Peach Posse'

Child 1 Name *

Child 1 Age *

Child 1 DOB *

Child 2 Name

Child 2 Age

Child 2 DOB

Address *

City, State, Zip *

Parent(s) Name *

Email Address *

Telephone (H)

Telephone (Cell 1)

Telephone (Cell 2)

Child Allergies 1

Child Allergies (2)

Any additional information

Emergency Contact (after parent)

Name(s) of others who have permission to pick up your child(ren) (1)

PLEASE make them aware they will need to present ID.

Relation to child (1)

Name (2)

PLEASE make them aware they will need to present ID.

Relation to child (2)

Name (3)

PLEASE make them aware they will need to present ID.

Relation to child (3)

I am participating upon the agreement and understanding that I am hereby waiving and releasing both the meeting facilities and The Peach Blossoms/ Peach Posse’ Girls Co-Op Program, its employees, participants and affiliates, from any and all claims, costs, liabilities, expenses, judgements, attorney fees and court costs, if there are illnesses or injuries arising out of our families participation in their program. - - - - - - I also release the meeting facilities and The Peach Blossoms/Peach Posse’ Girls Co-Op Program against any and all claims except illness and injury resulting from gross negligence or willful misconduct on the part of either the meeting facility or Program. - - - - - *I (select one below) agree / disagree to have photos of my child on the Peaches website, flyers and/or brochures to be used for advertisement purposes only. *

Agree
Disagree

Parent Signature (type your name) *

Date *

How did you hear about us?

Internet
Charter member
PGC Event

$40 Annual Membership Fee

To complete enrollment , Please click SUBMIT to go to payment page.

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