Selah Online Registration

Registration

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Welcome to Selah Gymkids!
Please complete the following registration form.
If the medical fields do not apply to your child or situation, just leave BLANK. Do not write None. Thank you!

* 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

Provide two add'l Authorized Emergency / Pick-up Contacts; include name, relation, and phone number.*

Health Insurance Provider*

Social Media Consent (yes/no)*

Doctors name & phone*

Dentists name & phone*

Preferred Hospital*

Living w/both parents (yes/no)*

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

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

Who is your employer?

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*

Additional Info

School

Grade Level*

Health History/ Special Needs*

Allergies/ Medications*

Medications (Leave blank if NONE)*

Primary Doctor & phone*

Immunization Notes*

Date last seen by Doctor*

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School

Grade Level*

Health History/ Special Needs*

Allergies/ Medications*

Medications (Leave blank if NONE)*

Primary Doctor & phone*

Immunization Notes*

Date last seen by Doctor*

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School

Grade Level*

Health History/ Special Needs*

Allergies/ Medications*

Medications (Leave blank if NONE)*

Primary Doctor & phone*

Immunization Notes*

Date last seen by Doctor*

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School

Grade Level*

Health History/ Special Needs*

Allergies/ Medications*

Medications (Leave blank if NONE)*

Primary Doctor & phone*

Immunization Notes*

Date last seen by Doctor*

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School

Grade Level*

Health History/ Special Needs*

Allergies/ Medications*

Medications (Leave blank if NONE)*

Primary Doctor & phone*

Immunization Notes*

Date last seen by Doctor*

Add Another Student

Required Policies

(Show-Hide Details)

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)

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

Credit Card

Required Policies

(Show-Hide Details)