Capitol City Gymnastics Online Registration

Registration

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Welcome to CAPITOL CITY GYMNASTICS! In addition to your class fee, new families will also be charged a $50 annual registration fee. Returning families will be charged the same fee on an annual basis. Registration fee does not apply for special events, summer camps, or open gym. Discounts will not automatically apply. Please contact the office if you are eligible for discounts & we will apply credits before pmt is made. *USE CHILD'S LAST NAME FOR FAMILY NAME* *FEE CHARGED FOR CC TRANSACTIONS*

* 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 (NOT Contact #1 or #2) - First & Last Name, Relationship to Student & Phone*

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

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*

Type*

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Military Disc 10% (add Military # below); Multi Child Discounts - 2nd Child 10%, 3rd+ Children 15%

Groupon Discount/Voucher #

Disabilities (Leave blank if NONE)

Special Needs (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*

Additional Info

Military Disc 10% (add Military # below); Multi Child Discounts - 2nd Child 10%, 3rd+ Children 15%

Groupon Discount/Voucher #

Disabilities (Leave blank if NONE)

Special Needs (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*

Additional Info

Military Disc 10% (add Military # below); Multi Child Discounts - 2nd Child 10%, 3rd+ Children 15%

Groupon Discount/Voucher #

Disabilities (Leave blank if NONE)

Special Needs (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*

Additional Info

Military Disc 10% (add Military # below); Multi Child Discounts - 2nd Child 10%, 3rd+ Children 15%

Groupon Discount/Voucher #

Disabilities (Leave blank if NONE)

Special Needs (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*

Additional Info

Military Disc 10% (add Military # below); Multi Child Discounts - 2nd Child 10%, 3rd+ Children 15%

Groupon Discount/Voucher #

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Add Another Student

Required Policies

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Questions or Concerns

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*

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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)

Contact #2

How can we contact you?

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

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Questions or Concerns

Payment Information

Credit Card

Required Policies

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