Kids in Action gymnastics Academy Online Registration

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Welcome to Kids in Action Gymnastics Academy! We are pleased you've chosen us. Complete the Registration form below and you will receive an email reply shortly. If you need assistance with this form please call our office at 847-381-6141.

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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 Name and Phone Number*

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

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

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilites/Special Needs

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

PARENT'S PLEASE BE ADVISED:

* COACHES CAN BE SUBJECT TO CHANGE WITHOUT NOTICE.
* KIAGA RESERVES THE RIGHT TO CANCEL OR MERGE CLASSES AS REQUIRED

All enrollments are reviewed and fees adjusted for applicable discounts within 1 business day.

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilites/Special Needs

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

PARENT'S PLEASE BE ADVISED:

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Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilites/Special Needs

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

PARENT'S PLEASE BE ADVISED:

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilites/Special Needs

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

PARENT'S PLEASE BE ADVISED:

Enroll in Classes

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Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilites/Special Needs

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

PARENT'S PLEASE BE ADVISED:

Enroll in Classes

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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*

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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)

Contact #2

How can we contact you?

Student #1

Additional Info

PARENT'S PLEASE BE ADVISED:

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

PARENT'S PLEASE BE ADVISED:

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Student #3 (Show-Hide Details)

Additional Info

PARENT'S PLEASE BE ADVISED:

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

PARENT'S PLEASE BE ADVISED:

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

PARENT'S PLEASE BE ADVISED:

Enroll in Classes

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Questions or Concerns

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