Registration
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All initial and one-time fees will be charged to your credit card as soon as registrations are received unless otherwise arranged with our office staff. These fees include, but are not limited to Membership fees, first month's tuition, Birthday party deposit, Back handspring clinics, and holiday parties.
How did you hear about us? *   Referral Name:         * - denotes required fields
Family Information:
Family Last Name:
Parent / Guardian First Name:* Last Name: * Type:*
Home Phone: * Cell #: Work #:
Email:* (Emails are kept confidential)
 
Employer:
Employer Phone:
Employer Notes:
 
Parent / Guardian First Name: Last Name: Type:
Home Phone: Cell #: Work #:
Email: (Emails are kept confidential)
 
Home Address: *
City: * State: * Zip: *
Home Phone: *
Emergency Contact Info:
(Not Parent / Guardian, Parent / Guardian)
 

Student #1 Information:
Student's First Name: * Last Name: *
Student Gender:  Birth Date: * (format=mm/dd/yy)  
Student Email:
Disabilites:
Special Needs:
Allergies:
Medications:
Primary Doctor:

Classes (max 15)
Select Class #1: * _______________   
Select Class #2: _______________   
Select Class #3: _______________   
Select Class #4: _______________   
Select Class #5: _______________   

Student #2 Information:
Show-Hide Details
Student's First Name: Last Name:
Student Gender:  Birth Date: * (format=mm/dd/yy) 
Student Email:
Disabilites:
Special Needs:
Allergies:
Medications:
Primary Doctor:

Classes (max 15)
Select Class #1: * _______________   
Select Class #2: _______________   
Select Class #3: _______________   
Select Class #4: _______________   
Select Class #5: _______________   

Student #3 Information:
Show/Hide Details
Student's First Name: Last Name:
Student Gender:  Birth Date: * (format=mm/dd/yy) 
Student Email:
Disabilites:
Special Needs:
Allergies:
Medications:
Primary Doctor:

Classes (max 15)
Select Class #1: * _______________   
Select Class #2: _______________   
Select Class #3: _______________   
Select Class #4: _______________   
Select Class #5: _______________   

Student #4 Information:
Show/Hide Details
Student's First Name: Last Name:
Student Gender:  Birth Date: * (format=mm/dd/yy) 
Student Email:
Disabilites:
Special Needs:
Allergies:
Medications:
Primary Doctor:

Classes (max 15)
Select Class #1: * _______________   
Select Class #2: _______________   
Select Class #3: _______________   
Select Class #4: _______________   
Select Class #5: _______________   

Student #5 Information:
Show/Hide Details
Student's First Name: Last Name:
Student Gender:  Birth Date: * (format=mm/dd/yy) 
Student Email:
Disabilites:
Special Needs:
Allergies:
Medications:
Primary Doctor:

Classes (max 15)
Select Class #1: * _______________   
Select Class #2: _______________   
Select Class #3: _______________   
Select Class #4: _______________   
Select Class #5: _______________   
 
Enter your Full Name: *   
 
 
Comments:  

Payment Method:*  
Credit Card Verification:
   
Name as it appears on card: *  
Card Type: *   Card Number: *  
Card Expiration Month: *   Exp Year: *  
 
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