Rainbow Gymnastics Online Registration

Registration

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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*

Preferred Hospital for Treatment*

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone *

Work #

Cell # Receive Text Message Notifications

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 # Receive Text Message Notifications

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

T-Shirt Size

Disabilities*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor (Name & Number)

Medical / Injury Alert

Please choose the class that is age and skill appropriate.

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

T-Shirt Size

Disabilities*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor (Name & Number)

Medical / Injury Alert

Please choose the class that is age and skill appropriate.

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

T-Shirt Size

Disabilities*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor (Name & Number)

Medical / Injury Alert

Please choose the class that is age and skill appropriate.

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

T-Shirt Size

Disabilities*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor (Name & Number)

Medical / Injury Alert

Please choose the class that is age and skill appropriate.

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

T-Shirt Size

Disabilities*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor (Name & Number)

Medical / Injury Alert

Please choose the class that is age and skill appropriate.

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Please fill out ONE of the following Payment Methods

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

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

eCheck/Bank Draft

Required Policies

(Show-Hide Details)