*Name _______________________ *Birth Date ________________

*Address ________________________________________________

*City/State/Zip ___________________________________________

*Phone _________________ *Parent's Name __________________

Paid _________ *Pass # ________ Date Issued ________________

Comments ________________________________________________
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I understand that if my child misbehaves or is asked to leave for any reason that I am responsible for having them picked up immediately.

*Parent's Signature _____________________________________