Gem City Gymnastics & Tumbling, LLC Online Registration

Registration

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Welcome to Gem City Gymnastics & Tumbling, LLC. Please fill out this registration form. This form will provide the gym with your family and athlete information. You will be required to provide a credit card to keep on file, but will not be charged at this time. Please read through our policies carefully. After you finish registering, then you will be eligible to call or stop in to get enrolled into classes or lessons at GCCT. (217)224-8491

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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*

Primary Phone*

Additional Info

Emergency Contact Info*

Health Insurance Carrier

Contact #1

Contact #1 First Name*

Last Name *

Type*

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Home Phone

Work #

Cell #

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Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

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Employer

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Employer Notes

Contact #2

Contact #2 First Name

Last Name

Type

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Home Phone

Work #

Cell #

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*

Cell #*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Primary Doctor*

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

Disabilities (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Primary Doctor*

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

Disabilities (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Primary Doctor*

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

Disabilities (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Primary Doctor*

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

Disabilities (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Primary Doctor*

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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)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

Required Policies

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I Agree to All of the Above

Questions or Concerns

Payment Information

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)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Required Policies

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