Gym, Exercise and Sport Enrolment Form

Member's Name *

First Name

Last Name

Member's Date of Birth *

MM

DD

YYYY

Parent/Guardians Name *

First Name

Last Name

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Timeslot (select one or multiple) *

What is your preferred day/time slot?

Friday 1:40pm-2:10pm

Friday 2:20pm-2:50pm

Friday 3:30pm-4:30pm

Would you be interested in speaking with our Occupational Therapist about our services? *

Yes

Media consent *

As the parent/guardian of the child listed above, I give/do not give The Tippy Toe Co. Incorporated permission to use professional images and video for promotional purposes. This may include; media articles and editorials, TTTC website, print material (flyers, posters, etc), social media posts and grant applications.

Do give

Do not give

Subscribe *

To the TTTC emailing list to receive updates, the quarterly newsletter and other news and events.

I do want to subscribe

I do not want to subscribe