Encore Inc. Online Registration

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Welcome to EncoreGym! We are pleased that have chosen to join us here at Shadelands SportsMall. If you have any questions before you begin, you may email us at office@encoregym.com or contact us by phone, 925-932-1033. We look forward to seeing you soon here at EncoreGym.

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Referral Information

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Referral Name*

Family Information

Family Last Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Name & phone of an adult LIVING OUTSIDE YOUR HOME if unable to reach you in case of emergency*

Health Insurance Carrier*

Contact #1

Parent #1 First Name*

Last Name *

Relation to student*

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Home Phone *

Work #

Cell # *

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Portal Access (your email is your login)

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Contact #2

Parent #2 First Name*

Last Name*

Relation to student*

How can we contact you?

Home Phone

Work #

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Encore Inc.. Standard message and data rates apply. Reply STOP to opt out

Email (Emails are kept confidential)

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Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Disabilities*

Special Needs or Chronic Conditions*

Allergies*

Medications*

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Disabilities*

Special Needs or Chronic Conditions*

Allergies*

Medications*

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Disabilities*

Special Needs or Chronic Conditions*

Allergies*

Medications*

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Disabilities*

Special Needs or Chronic Conditions*

Allergies*

Medications*

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Disabilities*

Special Needs or Chronic Conditions*

Allergies*

Medications*

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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

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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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