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: