River City Gymnastics Online Registration

Registration

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* denotes required fields

Referral Information

How did you hear about us?*

Referral Name*

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or 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* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Release of Liability

As the legal parent or guardian, I release and hold harmless River City Gymnastics, Inc., its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control and supervision of River City Gymnastics, Inc., its owners and operators or in route to or from any of said premises.

I've read the above and agree.

Medical Emergency

The undersigned gives permission to River City Gymnastics, Inc., its owners and operators to seek medical treatment for the participant in the event they are not able to reach a parent or guardian. I hereby declare any physical/mental problems, restrictions, or condition and/or declare the participant to be in good physical and mental health. I request that our doctor/physician ________________ be called and that my child be transported to ______________________ hospital. Please include physicians' phone number _______________.

I've read the above and agree.

Payment Information

Tuition is due by the first of each month. If accounts are paid after the tenth of the month, there will be a $25.00 late fee applied to the account balance. There is a $20.00 returned check charge for any checks returned by the bank. River City Gymnastics, Inc. reserves the right to debit your card/ account monies owed if payment is not received for services rendered by the 20th of the month.

I've read the above and agree.

Auto Payment Agreement

I authorize River City Gymnastics, Inc. to initiate debit entries to my checking or credit card account I provided and to debit the same account monthly and to credit it in the event of error. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. This authorization is to remain in full force and effect until River City has received 30 days written notice of its termination in such time and in such manner as to afford River City and the bank/credit institution a reasonable time to act on it.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule

Please fill out CREDIT CARD Payment Method

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