All Fields are Required
Childs Name (eg Tom ONeill)
Age
Date of Birth
(dd/mm/yyyy)
Guardians Name(eg Pat ONeill)
Full Home Address
Phone Number (e.g.086XXXXXXX)
Email
GPs Name and Address
Allergies and Medical Conditions
Class
Please make a Selection
Day
Please make a Selection
Time
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Membership (required)
Please make a Selection
Membership 1 Child - €20
Membership 2 Children - €35
Family Membership - €55
Already Paid
IG Insurance (required)
Please make a Selection
Preschool Insurance - €10
Cougars 1&2 Insurance - €20
Cougars 3 Insurance - €20
Already Paid
Method of payment
Please make a Selection
Cash
Cheque
By ticking this box you agree to be responsible for all fees for the Full Term, including Membership, Insurance and Tuition.