MOT All*Stars Online Registration

Registration

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Welcome to the M.O.T. All-Stars online registration! Please provide your information below and click "Submit" when finished.

* denotes required fields

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 Info*

Health Insurance Carrier*

Interested in being Team Mom?*

Contact #1

Contact #1 First Name*

Last Name *

Relationship*

How Can We Contact You?

Home Phone *

Cell # *

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*

Relationship*

How can we contact you?

Home Phone *

Cell # *

Email* (Emails are kept confidential)

Confirm Email*

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level (Current School Year)*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Enter NONE if not applicable)*

Medications (Leave blank if NONE)

Primary Doctor

Skill Level Trying Out For?*

Position most experienced in?*

Interested in crossing over?*

Choose any filter to begin searching for additional classes.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level (Current School Year)*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Enter NONE if not applicable)*

Medications (Leave blank if NONE)

Primary Doctor

Skill Level Trying Out For?*

Position most experienced in?*

Interested in crossing over?*

Choose any filter to begin searching for additional classes.

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level (Current School Year)*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Enter NONE if not applicable)*

Medications (Leave blank if NONE)

Primary Doctor

Skill Level Trying Out For?*

Position most experienced in?*

Interested in crossing over?*

Choose any filter to begin searching for additional classes.

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level (Current School Year)*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Enter NONE if not applicable)*

Medications (Leave blank if NONE)

Primary Doctor

Skill Level Trying Out For?*

Position most experienced in?*

Interested in crossing over?*

Choose any filter to begin searching for additional classes.

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level (Current School Year)*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Enter NONE if not applicable)*

Medications (Leave blank if NONE)

Primary Doctor

Skill Level Trying Out For?*

Position most experienced in?*

Interested in crossing over?*

Choose any filter to begin searching for additional classes.

Enroll in Classes

Select Class *

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Account Information

Payment Method/schedule*

Membership Type*

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

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

Account Information

Credit Card

Required Policies

(Show-Hide Details)