E-mail Address: *
Parents Name: *
Parent Mobile Number: (xxx-xxx-xxxx)
Home Number: (xxx-xxx-xxxx)
School / Center: *
Coordinator:
Child 1 Name: *
Child 1 Birth Date: mm/dd/yy * Select Date
Child 1 Age: *
Child 1 Gender: *
Child 2 Name:
Child 2 Birth Date: mm/dd/yy Select Date
Child 2 Age:
Child 2 Gender:
Address: *
City: *
Zipcode: *
T-Shirt Size Child 1
T-Shirt Size Child 2
Please indicate the days of the week your child(ren) attend(s) school/center:
Allergies (if any), also provide any information we should be aware of:
Hold Harmless Agreement: In giving my child permission to participate in the Monkeynastix Program, I acknowledge that, while not common, any activity that involves motion involves risk of injury, ranging from minor such as bruises or sprains to more serious or catastrophic. I hereby release Monkeynastix Tennessee, LLC, their offices, owners, employees, volunteers and agents from any and all claims and damages to persons or property which might arise as a result of an accident occurring while my child/children participate in the Monkeynastix Program including class participation, shows, demonstrations, competitions and games. I hereby state that I have read and understood the above release and the terms and conditions listed in the Monkeynastix Registration brochure, and agree to comply with the requirements and regulations of the program as stated. *I agree
I do not agree

* Required