Tadpole 5-6yrs

Tadpole 5-6yrs (incl. 1 Supporter) Membership

Junior Membership Category
# of Members*
Please select the number of Memberships if you are completing a Family Subscription...
# Members*
Please select the number of Memberships if you are completing a Family Subscription...
Membership Requirements
In addition to membership fees, a $15 Piha High Visibility Vest is required to enter the water during sessions, if your child does not already own one.
Please select if you need a Vest:
- Piha High Visibilty Vest
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
Comments
This field is for validation purposes and should be left unchanged.

Tadpole 5-6yrs (incl. 1 Supporter) 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