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West Melbourne EVENT Registration Form
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Steps
1.
Student Information
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2.
Parent/Guardian Information (if applicable)
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3.
Emergency Contact Information (not a parent)
This section is complete
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4.
Activities
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Student Information
Please complete the online form below to register for classes. If you would like to contact us by phone, you may call (321) 837-7779. Payment can be made by check, credit card or cash at the Veterans Memorial Complex.
First Name
*
Last Name
*
Date of Birth
*
Date of Birth
Gender
*
Male
Female
Age at time of registration
*
Address1
*
Address2
City
*
State
*
Zip
*
Home Phone Number
ex: 555-555-5555
Primary Email Contact
Cell Phone Number
ex: 555-555-5555
Allergies / Medical Conditions
*
Continue
Parent/Guardian Information (if applicable)
Primary Guardian - Name
Secondary Guardian - Name
Primary Guardian - Phone Number
ex: 555-555-5555
Secondary Guardian - Phone Number
ex: 555-555-5555
Primary Guardian - Email
Secondary Guardian - Email
Relationship to Student
-- Select One --
Parent
Grandparent
Aunt
Uncle
Legal Guardian
Other
Relationship to Student
-- Select One --
Parent
Grandparent
Aunt
Uncle
Legal Guardian
Other
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Emergency Contact Information (not a parent)
Emergency Name
Emergency Number
ex: 555-555-5555
Relationship to student
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Activities
Please tell us what EVENT you are registering for. i.e. skate contest, back to school dance, etc.
Parent Signature
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Receive an email copy of this form.
Email address
This field is not part of the form submission.
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