Zephyr Violetta Club Application

BABYZ & KIDZ DYNAMICS

172 Woodport Rd., Suite B - Sparta, NJ 07871 - Toll-Free: 1.866.268.2694

www.bkdynamics.com

ZEPHYR VIOLETTA CLUB

"A CLUB FOR THE WHOLE FAMILY"

MEMBERSHIP APPLICATION

(Please fill out application in its entirety.)

MOTHER’S NAME ………………………………………………………...............…………………

ADDRESS………………………………………………………………..............…………....

CITY……….……………………..................……....... STATE………………………………..

ZIP CODE……………..............……… HOME PHONE #.........................................

EMAIL ADDRESS………..............………………………………………………………..…..

Please list the name(s) and information about your child(ren) below.

Feel free to continue your list on the reverse side of the application if need be.

(1) FIRST……………………………LAST……………..................MaleFemale

DATE OF BIRTH........................

(2) FIRST……………………………LAST……………..................MaleFemale

DATE OF BIRTH........................

(3) FIRST……………………………LAST……………..................MaleFemale

DATE OF BIRTH........................

(4) FIRST……………………………LAST……………..................MaleFemale

DATE OF BIRTH........................

                   REFERRED BY………………………………………………………………..........

                   Clothing brands of Interest………………………….………………….....

                   WOULD YOU BE INTERESTED IN A LAYAWAY PLAN……...……………..…

                   APPLICANT’S SIGNATURE………………………………… DATE…………….

                      ------------For Internal Purposes ONLY--------------

      Date Application Recv’d…………….........…….Status Notice………………………….........

Comments…………………………………………………………………………...................…