popSUP New Customer Registration

Name *
Name
Phone *
Phone
Emergency Contact *
Emergency Contact
In case of an emergency, who can we call?
Phone *
Phone
Can you swim? *
Describe, if any
Any additional notes, comments or special requests
Yes, I acknowledge that: *
Please check all of the boxes below
Digital Signature
Digital Signature
Please acknowledge the above with a digital signature by entering your full name below:
Date
Date