NAME: (please print)__________________________________________________________________
                                           Last, First, Middle Initial
AGE: (check box)    q Adult (13 or over)            q Child (0-12)                 

DATE OF BIRTH:  _______________      

GENDER:  (check box)    qMALE   qFEMALE

STREET ADDRESS: _____________________________________________________________
                                                                                                   Apt.#

TOWN___________________________________________________ZIP__________                                                                                      

MAILING ADDRESS:____________________________________________________
(if different than above)            Street                                                          Apt.#
_____________________________________________________
  Town                                                                Zip

PHONE: (_____)________-____________        PHONE 2:  (_____)________-___________
            Area Code                                                        Area Code

E-MAIL ADDRESS: (optional)_______________________________________________

SIGNATURE:___________________________________________________________

Parent’s Signature for Grade Six (6) and below

FOR STAFF USE ONLY

Today’s Date___________________                                          Privilege Expires: ___/__ _/___

Verify Customer’s ID w/Current Address: _____________           Staff Initials_____________________  

Customer Barcode:    22534 --__________________--________________