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Referral Information
How did you hear about us?
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Referral
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Referral Name
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Family Information
Family Last Name Last Name
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Where do you live?
Home Address
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City
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State
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Zip
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Home or Primary Phone
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Additional Info
Emergency Contact Info
(Not Contact #1 or #2)
Contact #1
Parent's Name First Name
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Last Name
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How Can We Contact You?
Home Phone
Work #
Cell #
Portal Access (your email is your login)
Email
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(Emails are kept confidential)
Confirm Email
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Portal Account Password
Confirm Portal Account Password
Contact #2
Emergency Contact First Name
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Last Name
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Phone Number
Father
Grandparent
Guardian
Mother
Parents
How can we contact you?
Home Phone
Work #
Cell #
Email
(Emails are kept confidential)
Confirm Email
Student #1
Student's First Name
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Last Name
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Gender
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Female
Male
Birth Date
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(format=mm/dd/yyyy)
Additional Info
Health Issues/Allergies
Special Needs (Leave blank if NONE)
Student #2
(Show-Hide Details)
Student's First Name
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Last Name
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Gender
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Female
Male
Birth Date
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(format=mm/dd/yyyy)
Additional Info
Health Issues/Allergies
Special Needs (Leave blank if NONE)
Student #3
(Show-Hide Details)
Student's First Name
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Last Name
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Gender
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Female
Male
Birth Date
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(format=mm/dd/yyyy)
Additional Info
Health Issues/Allergies
Special Needs (Leave blank if NONE)
Student #4
(Show-Hide Details)
Student's First Name
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Last Name
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Gender
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Female
Male
Birth Date
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(format=mm/dd/yyyy)
Additional Info
Health Issues/Allergies
Special Needs (Leave blank if NONE)
Student #5
(Show-Hide Details)
Student's First Name
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Last Name
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Gender
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Female
Male
Birth Date
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(format=mm/dd/yyyy)
Additional Info
Health Issues/Allergies
Special Needs (Leave blank if NONE)
Add Another Student
Required Policies and Agreements
Assumption of Risk
I realize that my child is willfully participating at Gym-Ken Gymnastics, Inc. I understand that all precautions will be taken to prevent accidents and will not hold academy authorities responsible for any injury resulting from their participation in class, open gym, etc. I certify that my child has not been advised to not participate by a qualified medical professional and that there are no health related reasons or problems which preclude their participation at Gymnastics.
I've read the above and agree.
I Agree to All of the Above
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Questions or Concerns
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