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EDGEWOOD SWIMMING

2012 Swimming Lessions Registration Form

*Required Fields

Please enroll my child(ren) in the following clinics
Child 1 Name*
Child 1 Age*
GROUP LESSON $95.00
	Session 1
	Session 2
PRIVATE LESSON
	Half Hour $25.00
	Hour $35.00

Child 2 Name
Child 2 Age
GROUP LESSON $95.00
	Session 1
	Session 2
PRIVATE LESSON
	Half Hour $25.00
	Hour $35.00
Total*
MEMBER INFORMATION
Name*
Level of Membership*
Street*
City*
State*
Zip*
Email Address*
Phone*

PAYMENT
Name on card*
Credit Card Number*
Exp. Date valid thru 10.31.2012*
Card type*

Credit Card Billing Address (only if different than listed above)
Street Address
City
State
Zip

	As the credit card holder, I hereby authorize The Edgewood Club, to charge my credit card for the selected membership category and future fees verbally approved by me. *