Participant's Name *

First Name

Last Name

Participant's Date of Birth *

MM

DD

YYYY

Participant's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian's Phone *

(###)

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Parent/Guardian's Cell *

(###)

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Parent/Guardian's Address (if different from participant)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Choose Your Number of Days *

2 Days per week $224/mo

3 Days per Week $294/mo

CREDIT CARD AUTHORIZATION *

I AUTHORIZE IGT TO CHARGE MY CREDIT CARD THE FULL AMOUNT ON A MONTHLY RECURRING SCHEDULE.

Card Holder's Name *

First Name

Last Name

Card Holder's Phone *

(###)

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