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EXTREME Tumble & Cheer
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Referral Information
How did you hear about us?
Crossroads Ad
Other
Referral
Social Media
Website
Referral Name
Family Information
Family Account Name Last Name
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Where do you live?
Home Address
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City
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State
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AK
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AR
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CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
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LA
MA
MD
ME
MI
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MS
MT
NE
NC
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NH
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OH
OK
OR
PA
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VA
VT
WA
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WV
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PR
VI
Zip
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Additional Info
Emergency Contact Info
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Contact #1
Contact #1 First Name
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Last Name
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Type
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Father
Guardian
Mother
Parent
How Can We Contact You?
Work #
Cell #
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Portal Access (your email is your login)
Email
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(Emails are kept confidential)
Confirm Email
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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
Father
Guardian
Mother
Parent
How can we contact you?
Work #
Cell #
Email
(Emails are kept confidential)
Confirm Email
Who is your employer?
Employer
Employer Phone
Employer Notes
Student #1
Student's First Name
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Last Name
*
Student Gender
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Female
Male
Birth Date
*
Cell #
Additional Info
Student Email
Disabilities
*
Special Needs
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Allergies
*
Medications (Leave blank if NONE)
Primary Doctor
Is your child allowed to take acetaminophen or ibuprofen? If so state which one(s).
Student #2
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Student's First Name
*
Last Name
*
Student Gender
*
Female
Male
Birth Date
*
Cell #
Additional Info
Student Email
Disabilities
*
Special Needs
*
Allergies
*
Medications (Leave blank if NONE)
Primary Doctor
Is your child allowed to take acetaminophen or ibuprofen? If so state which one(s).
Student #3
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
*
Female
Male
Birth Date
*
Cell #
Additional Info
Student Email
Disabilities
*
Special Needs
*
Allergies
*
Medications (Leave blank if NONE)
Primary Doctor
Is your child allowed to take acetaminophen or ibuprofen? If so state which one(s).
Student #4
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
*
Female
Male
Birth Date
*
Cell #
Additional Info
Student Email
Disabilities
*
Special Needs
*
Allergies
*
Medications (Leave blank if NONE)
Primary Doctor
Is your child allowed to take acetaminophen or ibuprofen? If so state which one(s).
Student #5
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
*
Female
Male
Birth Date
*
Cell #
Additional Info
Student Email
Disabilities
*
Special Needs
*
Allergies
*
Medications (Leave blank if NONE)
Primary Doctor
Is your child allowed to take acetaminophen or ibuprofen? If so state which one(s).
Add Another Student
Required Policies
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I Agree to All of the Above
Enter your Full Name
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November 21, 2024
Questions or Concerns
Comments
Payment Information
eCheck/Bank Draft
Bank Name
Account Type
Checking
Savings
Your Account Name
(Your name on your bank statement)
Bank Routing Number
(9-digit number)
Account Number
