Peoria Jump Start Kid's Activity Center Online Registration

Registration

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Thank you for your interest in our programs! Please fill out and submit the following form. Pending approval of your class choice, fees will be posted to your account. There is an annual registration fee of $35 a child or $60 a family. Once your registration & payment have been processed, the office staff will send you a receipt & confirmation email. If you have questions, please contact our office at 309-693-5867 or email info@jumpstartfun.com.

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Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

Health Insurance Carrier*

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone *

Work #

Cell #

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Who is your employer?

Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Who is your employer?

Employer

Employer Phone

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School

Grade Level

Are there any mental/learning delays or concerns we should be aware of?

List any known allergies/allergic reactions:

List any Medications:

Primary Doctor's Name & Phone # & Date of Last Exam*

Medical Insurance Carrier & Group or Policy Number:*

List any previous surgeries

List any previous broken bones

List any other health concerns

Please choose one class to attend once a week.

Enroll in Classes

Select Another Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School

Grade Level

Are there any mental/learning delays or concerns we should be aware of?

List any known allergies/allergic reactions:

List any Medications:

Primary Doctor's Name & Phone # & Date of Last Exam*

Medical Insurance Carrier & Group or Policy Number:*

List any previous surgeries

List any previous broken bones

List any other health concerns

Please choose one class to attend once a week.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School

Grade Level

Are there any mental/learning delays or concerns we should be aware of?

List any known allergies/allergic reactions:

List any Medications:

Primary Doctor's Name & Phone # & Date of Last Exam*

Medical Insurance Carrier & Group or Policy Number:*

List any previous surgeries

List any previous broken bones

List any other health concerns

Please choose one class to attend once a week.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School

Grade Level

Are there any mental/learning delays or concerns we should be aware of?

List any known allergies/allergic reactions:

List any Medications:

Primary Doctor's Name & Phone # & Date of Last Exam*

Medical Insurance Carrier & Group or Policy Number:*

List any previous surgeries

List any previous broken bones

List any other health concerns

Please choose one class to attend once a week.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School

Grade Level

Are there any mental/learning delays or concerns we should be aware of?

List any known allergies/allergic reactions:

List any Medications:

Primary Doctor's Name & Phone # & Date of Last Exam*

Medical Insurance Carrier & Group or Policy Number:*

List any previous surgeries

List any previous broken bones

List any other health concerns

Please choose one class to attend once a week.

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Please fill out ONE of the following Payment Methods

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

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number

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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)

Who is your employer?

Contact #2

How can we contact you?

Who is your employer?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

eCheck/Bank Draft

Required Policies

(Show-Hide Details)