Chauncey's Kids Club Membership Dues

Chanticleer Athletics

Customer Information

Child's Information

Child's Name* (first last)
Date of Birth*	ex: 4/24/04
School*
Grade*
T-Shirt Size*

Parent/Guardian Information

Parent/Guardian*
E-mail*
Address*
City/ State/ Zip*	/ /
Telephone*	ex: 8433492193
CCU Alumni*	Yes No If Yes, what year

Membership Fee, Payment Option

Membership Fee	$25.00
*	Pay by credit card

* = required field

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