Redwood Empire Gymnastics Online Registration

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Looking for potential classes? Please create your customer account here before continuing. Once your customer account is complete, you will be directed to log in, and from there you can search for open days and time in your desired class. Redwood Empire Gymnastics 434 Payran Street (Suite D) Petaluma, CA 94952

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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 (not self)*

Health Insurance Carrier*

Alt Authorized Pick Up Person

Emergency Contact (not self)

Contact #1

Contact #1 First Name*

Last Name *

Type*

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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

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Employer

Employer Phone

Employer Notes

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

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)

Cell # Receive Text Message Notifications

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Immunization Notes

Medical Policy Number*

Classes showing online are open for enrollment. Check carefully for the correct 'session' or month you are choosing. Please give us a call if you have questions on classes not visible online 707.763.5010. We keep waitlists for classes that are currently full.

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell # Receive Text Message Notifications

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Immunization Notes

Medical Policy Number*

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell # Receive Text Message Notifications

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Immunization Notes

Medical Policy Number*

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Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell # Receive Text Message Notifications

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Immunization Notes

Medical Policy Number*

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell # Receive Text Message Notifications

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Immunization Notes

Medical Policy Number*

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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)

Who is your employer?

Contact #2

How can we contact you?

Who is your employer?

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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