Basketball Skills Clinic and Kidz Fit Trial Registration

Member Status*

Expiration Date (if known please enter):

Send membership information?*

Yes
No

Class Participant Information

First Name*

Last Name*

Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Cell Phone*

Home Phone*

Email*

Date of Birth*

Gender*

Male
Female
Unspecified

Emergency Contact Information

First Name*

Last Name*

Phone*

Emergency Contact Secondary Phone

Relationship to Primary Account Holder*

If Other, Please Specify

I am registering for*

Free Basketball Skills Clinic - Ages 5-7
Free Basketball Skills Clinic - Ages 8-12
Free Trial Kidz Fit Youth Fitness Program

If you are a member of a Commonpoint Queens program, please list which program

Learning Bridges
After School
Early Childhood
Summer Camp
Youth Sports
Other

Please read our COVID-19 waiver at http://www.commonpointqueens.org/wp-content/uploads/2021/01/Covid-19-Waiver-CPQ-Families-Minors-As-of-8-31-20.pdf and attach a signed copy