River City Gymnastics Online Registration

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Referral Information

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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*

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Work #

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Confirm Email*

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Confirm Portal Account Password

Who is your employer?

Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 First Name

Last Name

Type

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Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Who is your employer?

Employer

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Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

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Primary Doctor*

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Student's First Name*

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Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

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Primary Doctor*

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Student's First Name*

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Medications (Leave blank if NONE)

Primary Doctor*

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Student's First Name*

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T-Shirt Size

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Medications (Leave blank if NONE)

Primary Doctor*

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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

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

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Address Line 1

Address Line 2

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Zip*

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Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number

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

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Student #2 (Show-Hide Details)

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Student #3 (Show-Hide Details)

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Student #4 (Show-Hide Details)

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