Partners For Progress Rider Registration

Client Information

Ethnicity

Parent / Legal Guardian

If client is a minor there must be a parent/guardian indicated below.  If address is same as the rider it does not need to be re-entered.
 

Second Parent / Legal Guardian

If address is same as the rider it does not need to be re-entered.
 

Emergency Medical Information

Billing Information

If you would like your credit card charged for session fees when due.  Provide your credit card information at the PFP office.  An additional charge of .025 percent will added to each invoice to cover credit card processing fees.
I would like my credit card charged for session fees when due *

Fundraising Options

Select one of the two choices below: *

Photo Release

I authorize the use and reproduction by Partners For Progress NFP and/or Pediatrics in Motion of any photographs and any other audio-visual materials taken of me for promotional material, educational activities, exhibits or for any other use for the benefit of the program. *
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