Middle Schoolers

COMING THIS FALL!

Beyond the Bell for Middle Schoolers

Participant's Name

First Name

Last Name

Date of Birth

YYYY

Participant's Email

Participant's Phone

(###)

###

####

Address

Age

Grade

Food Allergies and Other or NONE

Parent/Guardian's Name

First Name

Last Name

Parent/Guardian's Phone

(###)

###

####

Parent/Guardian's Cell

(###)

###

####

Emergency Contact and Phone #

Choose Your Days

Tuesdays 3pm-6pm

Wednesdays 3pm-6pm

Thursdays 3pm-6pm

CREDIT CARD AUTHORIZATION

I AUTHORIZE IGT TO CHARGE MY CREDIT CARD FOR THE FULL AMOUNT FOR THE DAYS ATTENDING ON A RECURRING SCHEDULE

Cardholder's Name

First Name

Last Name

Card Holder's Phone

(###)

###

####

Card Holder's Email

Card Number

CVV Code

Expiration Date