First Name

Last Name

  Primary Email Address

    Secondary Email Address

  School attending

  Home Phone #

  Parents Cell #

1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th   Grade Currently In

  Parents Name

choose one below 2011 Fall Kidz Power $60   Camp- clinic you are Registering for

choose one below Westside Club Sptbg Pavilion Grvl   Location  ( Pre Kidz Pwr is WSC only currently)

   Print form and mail to Club South  815 Pirate Cove Inman, SC 29349