TOPKIDS
			Enrollment Form
Name: ____________________________			Birthday: ________		School: ___________________			Grade: ____
Parent / Legal Guardian’s Name: ______________________					Email _________________________
Primary Phone: _________________________				Cell Phone: ____________________________
Address: _________________________________				City:_____________________				Zip Code _____
Emergency Contact: Name: __________________________					Phone: _________________________
Courses			Duration		Fee
Subtotal
Subtotal (Discount Applied)
Books & Learning Materials
Registration
Total
Charge My	VISA: ______		Master Card: ______		Expiration Date: __________________
Cardholder's Name: _____________________________				Card Number: _____________________________
Billing Address: _____________________________________________________________								Zip Code _____
Signature: _______________________________________________							Date : _______________
You must read and sign the following statement for your child/children to register.
I hereby waive and release the TOPKIDS CENTER from any and all liability for any injuries or illness that
my child/children may have occurred in attending the activities provided by TOPKIDS CENTER. I have no
knowledge of any physical impairment that would affect or be affected by my child/children’s participation
in the class in TOPKIDS CENTER. I give my permission for instructors of TOPKIDS CENTER to administer
emergency first aid and/or to seek emergency medical care or send my child/children to the hospital
if necessary. I understand every effort will be made to contact me first. I agree to pay all expenses
associated if this action is taken.
Signature: _______________________________________________							Date : _______________
	www.TopkidsCenter.com			Call  (626) 359-2000			Fax  (626) 359-2160