Order Number Parent's Name * Street Address * City State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Email * Phone * Name of Child 1 * Child 1 Age * Child 1 Sex * Male Female Child 1 Birthdate * Name of Child 2 Child 2 Age Child 2 Sex Male Female Child 2 Birthdate Do you give us permission to video tape your child * Yes No Is there any information we should know about your child? Cost * Agree I understand that the cost for the first child is $50 and each additional child is $45. Payments may be mailed to 307 Brookside Dr., Parkersburg, IA 50665 or paid during the first class session. Please make checks payable to Empowering Fitness.
