Online Program & Class Registration Form
CHILD/STUDENT INFORMATION! First Name:
! Last Name:
! Street ! Apt #:
! City: ! State:
!Zip Code:
! Home Phone:
! Birthdate:
! Email:
! Age:
! Gender:
! Grade:
! Food Allergies: N if !Yes, explain and list all:
Name of your child's Pediatrician:
Pediatrician's Phone Number with area code:
PARENT/GUARDIAN (Emergency Contact)
! First Name:
! Last Name:
! Email:
! Home Phone:
! Work Phone:
! Cell Phone:
PROGRAM/CLASS INFORMATION (You are registering your child for)
! Name of Program: Nutri-Kick (martial arts & nutrition education) , Nutri-Fit (Functional youth fitness training & nutrition education) Palate-Training (parents, babies & toddlers) Tween & Teen Boot Camp Fitness (exercise/fitness training only) Healthy & Fit Kids Klub ( 3 hour all-inclusive, nutrition, fitness & healthy cooking)
Healthy Cooking Class (type in title/class name here:____________________________________)
Other program name: (type in here)
! Number of weeks: 1,2,3,4,5,6,7,8,9, 10, 11, 12 (choose one)
! Session: Winter, Spring Summer or Fall !Year: 2010, 2011, 2012, 2013, 2014, 2015
! Session Day of the Week: Monday, Tuesday, Wednesday, Thursday, Friday Alt. Saturday
! Session Time: ____________!start time _______________!end time
! Full Program Tuition Cost $: ______________________Fill -in price (numeric value)
! Annual Family Membership Fee: _____New($50)/yr. ____Returning($25)/yr.
PAYMENT INFORMATION FILL OUT AND COMPLETE ALL THAT APPLY
Check (check box here)
Make payable and Mail to: One Potato Two Tomato P.O Box 357 Syosset, NY 11791
Credit Card: ____Mastercard or _____Visa (check one box)
Credit Card #:
Expiration date:
CVV Code (3 digit code on back of card):
Total Amount + membership fee (once a year based on date of 1st enrollment): fill-in dollar amount in numeric value.
If you would like to register more that one child or enroll with a friend to receive a 10% discount for a sibling or friend, check box here and we will contact you for further info before processing your registration with along payment.
Registration Policies and Liability Waiver
(Read and sign below to complete your online registration you're almost done!
- All payments are due in full, at time of registration/enrollment.
- All registration forms must be completed & signed by parent/guardian.
- A 10% sibling or refer a friend discount is available when enrolling together in the same semester group program.
- A "Buddy pass" is available for any student already enrolled in any of our programs to give to a friend to come along with them and try a FREE class!
-
Yearly one -time annual (12 months) family & kids center membership fee
(new, first-time families = $50.00, returning families = $25.00) - No refunds or make-ups are given or provided for any missed group classes/sessions.
WAIVER INFORMATION
1.- I/We, the parent(s)/guardian(s) of the above-named candidate/student/child for participation in One Potato Two Tomato's healthy lifestyle nutrition & fitness programs and hereby give my/our approval to participate in any and all related activities including transportation to and from our center and schools (only if transportation is part of the program and deemed applicable)
2.-
3.-
4.-
! Electronic Signature Box : (Type your Name:)
! indicates required information
submit form button (add here) and generate from with all info fromTNT to One Potato Two Tomato email: info@onepotatotwotomato.com
Join One Potato Two Tomato® today and sign up to learn how fun fitness and healthy lifestyle habits can transform the way your child thinks, plays, and lives. Choose the program that's right for your family. Our registered dietitians and youth fitness trainers will be happy to give you a tour and answer all of your questions. We're just a phone call away. Don't let another day pass by. Change your child's life today, and enjoy the benefits for years to come!