The Master's School of Gymnastics Online Registration

Registration

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Please fill out this form as thoroughly as you can. Items marked with a red asterisk are required to submit the form. Anything entered here will override the information we have currently in our system. This new system requires a valid credit card to be on file for each account, but you will still have the power to detemine the method of your payment in the office. All information on this form is kept confidential and will not be shared with anyone outside our offices.

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Referral Information

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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

Primary Parent/Guardian First Name*

Last Name *

Type*

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Home Phone

Work #

Cell # Receive Text Message Notifications

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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

Second Parent/Guardian First Name

Last Name

Type

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Home Phone

Work #

Cell # Receive Text Message Notifications

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

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Primary Doctor

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Student Gender*

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T-Shirt Size

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Primary Doctor

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Additional Info

T-Shirt Size

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Special Needs (Leave blank if NONE)

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Medications (Leave blank if NONE)

Primary Doctor

Student #4 (Show-Hide Details)

Student's First Name*

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Student Gender*

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

Additional Info

T-Shirt Size

School

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Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

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Medications (Leave blank if NONE)

Primary Doctor

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Student's First Name*

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

Additional Info

T-Shirt Size

School

Grade Level

Transportation

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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Credit Card

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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)

Who is your employer?

Contact #2

How can we contact you?

Who is your employer?

Student #1

Additional Info

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

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Student #5 (Show-Hide Details)

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