Landmark Community Center Registration

Registration Type *

Individual Family

First Name *

Middle Name

Last Name *

Either email address or phone number are required.

Email Address

Mobile Phone Number

Date Of Birth *

Gender *

Address *

City *

State *

Zip Code *

I am disabled

Type of disability

Emergency Contact - Name *

Either emergency email address or phone number are required.

Emergency Contact - Email Address

Emergency Contact - Phone Number

Rank the top 3 areas you plan to use the most. 1 being the most

Rank #1

Rank #2

Rank #3

List of Available Programs

Aerobics
Basketball
Dance
Games
Music
Volleyball
Yoga

By submitting this form, I hereby acknowledge that I have completely read and fully understand the content . *
(click here to download waiver)

Signature Box *

Why do we need this information
This is a recreation facility. It is important that we know the demographics. Programs and times for programs will be designed based on age groups and gender. It is in the best interest of the guest to be able to participate in what they enjoy and are able to participate in. It is important to understand the factors for an individual to participate in activities.