Encore Inc. Online Registration

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Welcome to EncoreGym! We are pleased that have chosen to join us here at Shadelands SportsMall. If you have any questions before you begin, you may email us at office@encoregym.com or contact us by phone, 925-932-1033. We look forward to seeing you soon here at EncoreGym.

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Referral Information

How did you hear about us?*

Referral Name*

Family Information

Family Last Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Name & phone of an adult LIVING OUTSIDE YOUR HOME if unable to reach you in case of emergency*

Health Insurance Carrier*

Contact #1

Parent #1 First Name*

Last Name *

Relation to student*

How Can We Contact You?

Home Phone *

Work #

Cell # * Receive Text Message Notifications

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Parent #2 First Name*

Last Name*

Relation to student*

How can we contact you?

Home Phone

Work #

Cell # Receive Text Message Notifications

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Disabilities*

Special Needs or Chronic Conditions*

Allergies*

Medications*

Enroll in Classes

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Disabilities*

Special Needs or Chronic Conditions*

Allergies*

Medications*

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Disabilities*

Special Needs or Chronic Conditions*

Allergies*

Medications*

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Disabilities*

Special Needs or Chronic Conditions*

Allergies*

Medications*

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Disabilities*

Special Needs or Chronic Conditions*

Allergies*

Medications*

Enroll in Classes

Select Class

Add Another Student

Required Policies

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Questions or Concerns

Comments

Payment Information

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

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Student #3 (Show-Hide Details)

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Student #4 (Show-Hide Details)

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Student #5 (Show-Hide Details)

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Questions or Concerns

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