Belay Certification Class
Name:
*
Member?
*
Yes
No
Phone #:
*
E-mail:
*
Street Address:
*
City:
*
Zip Code:
*
If you would like to schedule a class for a date other than listed below choose the "Other Date" option and Tim Hendrix will call you to set up an appointment.
Class:
*
October 11
October 25
November 8
November 22
December 6
December 20
Other Date
Payment Options
Choose One:
*
Courthouse Account
Visa/Mastercard
Discover
Credit Card #:
Name on Card:
Expiration Date:
WAIVER OF LIABILITY & REFUND POLICY
The Courthouse Athletic Club requires that every person participating in this activity to read and agree to the above Acknowledgment & Waiver of Liability ("Release"). If a minor will be participating in the activity, an authorized parent or legal guardian must execute the Release on behalf of the minor.
By submitting this form, I acknowledge that I have carefully read the Release and understand it. I am 18 or more years of age. By checking this box, I hereby acknowledge and agree to be bound by the Release. If a person participating in the activity is a minor, I hereby represent that I am the parent or legal guardian of the minor and am authorized to execute this Release with regard to the minor.
Word Verification: