Junior Family 2 Children + 2 Adults

Junior Family 2 Children (incl. 2 Parent/Guardian as Associate) Membership

Junior Membership Category
# of Members*
Please select the number of Memberships if you are completing a Family Subscription...
Membership Requirements
*Included in the membership fees is a $25 equipment subsidy fee per child. A $15 Piha high visibility vest is required to enter the water during sessions, if your child does not already own one please select below.
Please select from the following:
- Piha High Visibility Vest Member 1
- Piha High Visibility Vest Member 2
Total
$ 0.00
Contact Details - Member 1
Name*
First Last
Confirmation email to you*

Enter your email in this box and we will send you a confirmation of your membership.
Postal Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Mobile Phone
Gender*
Date Of Birth*

Day
Month
Year
ICE - Emergency Contact
Required for all Junior members - recommended for all!
Name*
First Last
Relationship to Member*
Home Phone*
Mobile Phone
Contact Details - Member 2
Name*
First Last
Email
Home Phone
Mobile Phone
Gender*
Date Of Birth*

Day
Month
Year
Contact Details - Member 3
Name*
First Last
Email
Home Phone
Mobile Phone
Gender*
Date Of Birth*

Day
Month
Year
Contact Details - Member 4
Name*
First Last
Email
Home Phone
Mobile Phone
Gender*
Date Of Birth*

Day
Month
Year
Contact Details - Member 5
Name*
First Last
Email
Home Phone
Mobile Phone
Gender*
Date Of Birth*

Day
Month
Year
Contact Details - Member 6
Name*
First Last
Email
Home Phone
Mobile Phone
Gender*
Date Of Birth*

Day
Month
Year
Untitled
- First Choice
- Second Choice
- Third Choice
Comments
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Junior Family 2 Children (incl. 2 Parent/Guardian as Associate) Membership

Membership Requirements

Contact Details - Member 1

ICE - Emergency Contact

Contact Details - Member 2

Contact Details - Member 3

Contact Details - Member 4

Contact Details - Member 5

Contact Details - Member 6