2014 SIGN UP

1 FORM PER CHILD

1:00 – 2:00 pm              Ages 5-9

2:00 – 3:00 pm              Ages 10-14

F                    F ULL  (16 Days)  $130             HALF (8 Days) $70          QUARTER (4 Days) $40

                                                    CLINIC DATES (Please circle dates attending):                                            

                               TUE   THR    TUE    THR   TUE   THR    TUE   THR

             JUNE –       3         5         10       12       17       19       24       26

             JULY -         8         10       15       17       22       24       29       31

            NAME:_________________________________________________     AGE:___________

                        SIGN UP / CHECKS PAYABLE:          MARK MCPHILLIPS

                                                                     11704 CLAYCHESTER DR.       TOTAL: ___________

                                                                     ST. LOUIS, MO 63131

                                                                   QUESTIONS: MARK MCPHILLIPS – 513.519.1207