Caregiver's Name *

First Name

Last Name

Phone *

(###)

###

####

Child's Name *

First Name

Last Name

Child's Birthday *

MM

DD

YYYY

T-Shirt Size *

4T

5/6

X-Small (7)

Small (8)

Medium (10)

Options *

Little Pears: 2 Days/week (Tuesday/Thursday)

Prickly Pedals: 3 Days/week (Monday/Wednesday/Friday)

Weeks you wish to enroll: *

(please select at least 3)

Week 1: July 8-12

Week 2: July 15-19 (FULL)

Week 3: July 22-26 (FULL)

Week 4: July 29- August 2 (FULL)

Week 5: August 5-9

Week 6: August 12-16

Pricing Tier *

Please see pricing above!

Pay It Forward

True Cost

Supported

Name of your child's other primary caregiver:

First Name

Last Name

What is the other primary caregiver's phone number?

(###)

###

####

Do you agree to the following statement? "I (we), the parent or legal guardian of the above listed child(ren) grant permission for my child(ren) to participate in Prickly Pears and to receive medical treatment if necessary. If I (we), or the listed emergency contacts cannot be reached, I (we) give our permission to the staff to secure services of a licensed physician to provide necessary care, including anesthesia, for our child(ren)'s well-being. I (we) also release and agree to hold harmless Prickly Pears and all its participants and staff from any liability and assume all risk from injury, damage or expenses as the result of participation in Prickly Pears. I (we) also authorize Prickly Pears Staff to administer basic first aid to our child(ren)." *

Yes, I agree

Do you agree to the following statement? "I authorize the use of photos taken during Prickly Pears for purposes of publicity on websites, Facebook pages and/or promotional materials. (We never use names of children in such materials.)" *

Yes, I agree

No, I do not agree

How will you be paying? *

$50 non-refundable deposit due at time of registration. Spot is not secured until deposit is received. Remaining balance due June 1st

Venmo @Emily-Rybolt

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