Teen Climbing Club Registration and Billing Agreement This form is for club registrations at Earth Treks Climbing and Fitness in Maryland and Virginia. Please do not submit the form until you have received notification from Earth Treks indicating a spot is available for your child. Rec Club dues are charged automatically on a monthly basis, September through June. The first month of billing includes an added start up fee of $25.Climbing Center*SELECT ONECrystal City Climbing CenterRockville Climbing CenterTimonium Climbing CenterCrystal City: Which Time Slot?*SELECT ONEWednesday 6:30-8:30pmNote that participants are signed up for specific days/times and can only attend those sessions. Please select the day and time that was emailed to you.Rockville: Which Time Slot?*SELECT ONEMonday 6:30-8:30pmTuesday 6:30-8:30pmThursday 6:30-8:30pmNote that participants are signed up for specific days/times and can only attend those sessions. Please select the day and time that was emailed to you.Timonium: Time Slot*SELECT ONEThursday 6:30-8:30pmNote that participants are signed up for specific days/times and can only attend those sessions. Please select the day and time that was emailed to you.Is the club participant an Earth Treks Member?No - Non Member ($95 per month)Yes - Member ($65 per month)The youth participating in the club must be an active Earth Treks member with ongoing monthly member dues to receive member pricing.For those participants who are not month to month gym members, club dues will be processed on the 1st of each month (or the first business day) via credit card. You must separately provide your credit card information via the secure Change my Billing Information Form. Under "Change Request" select "Update payment information on account".Authorized Monthly Club Dues - MemberMember - Teen Club ($65/month)Authorized Monthly Club Dues - Non MemberNon Member - Teen Club ($95/month)Participant Name* First Last Date of Birth* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Guardian Name* First Last Guardian Phone*Alternate PhoneGuardian Email* Enter Email Confirm Email Guardian Name 2 First Last Guardian 2 PhoneGuardian 2 Email Enter Email Confirm Email Any Comments or Questions?Registration and Billing Agreement Acknowledgment* Agree I authorize Earth Treks to process for payment my selected monthly Teen Climbing Club dues and understand that dues will be charged automatically on the 1st of each month (or the first business day) September through June. I understand that I may cancel at any time by providing no less than 10 days written notice via the Teen Climbing Club cancellation form prior to the applicable billing cycle. I also understand that the first month of billing includes an added start up fee of $25.NameThis field is for validation purposes and should be left unchanged.