Cub Club Registration

ATTENDEE INFORMATION (one form per child)
Child's name:
Birthdate:	(MM/DD/YY)
Sex:	Male Female
Allergies, limitations, medications:
Parent/Guardian Name:
Address:
City:
State:
Zip:
Email:
Home Phone:
Work Phone:
Mobile Phone:
Member of the Zoo:	Yes No
Member Number:
PROGRAM INFORMATION (Refer to brochure for #s and names)
Session #:
Series Name:
Fee:
Session #:
Series Name:
Fee:
Session #:
Series Name:
Fee:
Session #:
Series Name:
Fee:
Conservation & Science buttons:	Qty ($2 each)
If purchasing more than four classes, please complete an additional form.
Total:
PAYMENT INFORMATION
Card Type:
Card Number:
Expiration:	(mm/yy)
Security Code: (last three digits on back of card)
Total amount paid: