Registration Form

Richard Millman Presents The Millman Experience
122 Evening Shade Drive  •  Charleston, SC 29414
(843) 323-7340  •  Email: millmansquash@gmail.com

 

Camper’s/Attendee’s Name:

______________________________________________________

Parent’s Name:

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Home Address:

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City:

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State: _________Zip: _______ Age:__________

Phone: Home:

______________________________________________________

Alternative No.:

______________________________________________________

Email:

______________________________________________________

Please indicate which session(s) you are registering for:

______________________________________________________      

A 20% deposit is required to register for all programs

Payment information:
We accept personal check, cash, VISA, MasterCard, American Express, and PayPal.
Please make checks payable to The Squash Doctor.

Credit Card Payments:
VISA, MasterCard, AMEX card number:

______________________________________________________

Expiration Date:_______________________

Security Number:________________

PayPal (online link): www.paypal.com

If paying with PayPal, go to the PayPal website home page. The following options are on the top of the page: Personal, Business, Send, Request. Choose the Send option. On the next page put thesquashdoctor@yahoo.com in the first field, the amount you are sending in the next field (omit the $), press continue. The next page will have two options on the top: Friends or family and Goods or Services. Choose Goods or services to continue. The next page will require you to log in with your PayPal account information. Next is the review and confirmation page to finalize the transaction. Please indicate to whom you are sending payment for in the subject line, and the session(s) you are paying for in the message box with a return email and phone number. You will receive a confirmation email of the transaction.

Release (required):

In consideration of making facilities, and/or services available, I do hereby for and on behalf of myself and my heirs and legal representatives, release and forever the facility hosting this event and Richard Millman, from any and all claims and demands of every kind, nature and character which I may have or hereafter acquire for any and all damages or losses which may be suffered or sustained my me, or my child, in connection with these activities and all claims are hereby waived and released.

If under 18 years old, a parent or guardian signature is required.

Signature (parent):

______________________________________________________

Signature (child):

______________________________________________________

Date:

______________________________________________________

 

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