Matrix Gym Online Registration

Registration

Already a customer? Click here to login.

Welcome to The Matrix Gym! Please fill out the form completely or your registration may not be processed correctly. You are required to submit a valid credit card at the bottom of this form in order to enroll. Thank you for the opportunity to coach your athlete(s)!

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name*

Family Information

Family/Account Name Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Name and Number*

Health Insurance Carrier

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

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

Grade Level

Disabilities (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

Please make sure you are registering for the CORRECT LEVEL class. There are descriptions listed with each level class to make it easier for you. Class placement is based on ability, not the number of years taken. Coaches will let you know when your child is ready to move into the next level. If you would like to schedule an evaluation, please call us to arrange a time and day.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Grade Level

Disabilities (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Grade Level

Disabilities (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Grade Level

Disabilities (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Grade Level

Disabilities (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

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*

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

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

Required Policies

(Show-Hide Details)