Registration Form
Member Priority Registration through August 23rd.
If participant is under the age of 18, please fill in parent information and then list the participant in the space provided. All forms must be completed in full in order to be processed. Date of birth will default to 1901 if not provided.
Please Print Clearly
Parent / Guardian Last Name First Name Date of Birth
Home Address City State ZIP Code
Home Phone Work / Cell Phone E-mail m Check here if billing and home address are the same. If different fill out below.
Billing Address City State ZIP Code
How did you hear about us?
Please list any special needs, allergies or medical conditions we should be aware of.
Participant’ s Name |
Date of Birth |
Program |
Code Number |
Day & Time |
Cost |
Please consider rounding your payment up to make a small contribution to the Weinstein JCC $ T-Shirt Size: m YS m YM mYL m S m M m L m XL Method of Payment: m Cash m Check m AMX m MasterCard m Visa Credit Card # 3 digit security code Exp. Date Authorized Signature Are you a Weinstein JCC Member? m No m Yes / Weinstein JCC Account #
Date
If no, has participant ever taken a class at the Weinstein JCC before? m Yes m No
Registrations will not be processed without payment.
Total Amount $
There is a $ 10 processing fee for cancellation by registrants prior to the first class. No refunds will be made for withdrawals after a class has begun. Should the Weinstein JCC cancel a class, a refund will be made. Visit our website at www. weinsteinjcc. org for additional class information, Center information and additional registration forms.
Participation in any Weinstein JCC activities and use of recreational workout facilities involves a risk of accidental injury despite all safety precautions. I will assume all risks( of injury or illness) to my children or myself that may occur during participation in any activities or use of facilities at the Weinstein JCC. By signing this form, I acknowledge that I am aware of the potential risks of participating in activities and / or programs at the Weinstein JCC and agree to in no way hold the management, agents, or employees of the Weinstein JCC liable for any injury that I or members of my family may sustain.
I have read and understand the above statement.
Signature Date
36 weinsteinjcc. org • WEINSTEIN JCC MAGAZINE
Mail or Fax Registration to:
Carole and Marcus Weinstein Jewish Community Center 5403 Monument Avenue, Richmond, VA 23226 Fax # 804-285-3139 Questions? Call 804-285-6500