Register for the Wonder Girls BERGEN | ROCKLAND 2023 - 2024 Program

Name of Student

First Name

Last Name

Email of Student

Cell Phone of Student

(###)

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Name of Parent / Guardian

First Name

Last Name

Email of Parent / Guardian

Cell Phone of Parent / Guardian

(###)

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Grade

School

Do you have any allergies, health issues or take any medications that we should be aware of?

Emergency Contact

Please provide name and number.

Choose payment option

Pay $15 monthly membership fee

Pay $180 annual membership (receive 1 month free)