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Teaching integrity and respect while increasing confidence and strength through athletics

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Referral Information

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Parent Information

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City*

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Zip*

Primary Phone*

Additional Info

In case of emergency, who should we contact if the adults listed above are unavailable*

Health Insurance Carrier, Subscriber Name, and I.D. Number

Contact #1

Contact #1 First Name*

Last Name *

Type*

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Home Phone

Work #

Cell # *

Portal Access (your email is your login)

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Confirm Email*

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Contact #2

Contact #2 First Name

Last Name

Type

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Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Previous Injuries

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor and Phone Number

Please note that student arriving more than 5 minutes late to their class will have to warm up and stretch on their own.

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Previous Injuries

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor and Phone Number

Please note that student arriving more than 5 minutes late to their class will have to warm up and stretch on their own.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Previous Injuries

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor and Phone Number

Please note that student arriving more than 5 minutes late to their class will have to warm up and stretch on their own.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Previous Injuries

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor and Phone Number

Please note that student arriving more than 5 minutes late to their class will have to warm up and stretch on their own.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Previous Injuries

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor and Phone Number

Please note that student arriving more than 5 minutes late to their class will have to warm up and stretch on their own.

Enroll in Classes

Select Class

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Referral Information

Parent 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)

Additional Info

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Student #3 (Show-Hide Details)

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Student #4 (Show-Hide Details)

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Student #5 (Show-Hide Details)

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