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Medical Release
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CSMA Registration Form
Please print out & mail with payment to CSMA
Student Name
____________________________________
Date of Birth (under 18)
__________________
Class Number
__________________
Class Name
____________________________________
Cost $___________
Student Name
____________________________________
Date of Birth (under 18)
__________________
Class Number
__________________
Class Name
____________________________________
Cost $___________
Student Name
____________________________________
Date of Birth (under 18)
__________________
Class Number
__________________
Class Name
____________________________________
Cost $___________
Add Yearly Individual Membership ($55.00)
$___________
Add Yearly Family Membership ($90.00)
$___________
Contribution to the CSMA Scholarship Fund!
$___________
Total:
$___________
Please charge my credit card
(Visa/Mastercard Only)
:
Card # ____________________
Expiration Date _____________
Parent/Guardian or Adult Student Name
_____________________________
Phone (H) ____________________
Address
_____________________________
Phone (W)____________________
_____________________________
Email ________________________
_____________________________
Signature ___________________________________
(Parent/Guardian must sign if student is under 18 yrs. old)
Please note
: A medical release form must be on file at the office before students 18 or younger may begin activities at CSMA.
CSMA
,
330 East State Street, Ithaca, NY 14850