Glitch Fitness Online Registration

Registration

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Welcome to Glitch Fitness! We are so excited to have you join our fitness family! Please complete the registration form below. Additional classes and/or additional children can be added to this form, if needed. Please feel free to call or text if you have any questions at (702) 981-8737 or email us at Info@Glitchfitness.com.

* 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 Other Than Parent (Name, Phone, Relationship)*

Promo Code

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Cell # *

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?

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* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Special Needs/ Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Instructions

Select class for student #1 before adding additional students

To select a class or add additional class select blue "Select Class" button

To add additional child select "Add Another Student"

We will reach out to you upon submission to confirm all details.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Special Needs/ Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Instructions

Select class for student #1 before adding additional students

To select a class or add additional class select blue "Select Class" button

To add additional child select "Add Another Student"

We will reach out to you upon submission to confirm all details.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Special Needs/ Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Instructions

Select class for student #1 before adding additional students

To select a class or add additional class select blue "Select Class" button

To add additional child select "Add Another Student"

We will reach out to you upon submission to confirm all details.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Special Needs/ Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Instructions

Select class for student #1 before adding additional students

To select a class or add additional class select blue "Select Class" button

To add additional child select "Add Another Student"

We will reach out to you upon submission to confirm all details.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Special Needs/ Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Instructions

Select class for student #1 before adding additional students

To select a class or add additional class select blue "Select Class" button

To add additional child select "Add Another Student"

We will reach out to you upon submission to confirm all details.

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule*

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

Jackrabbit Technologies' class management platform & registration portal is trusted by 1000s of
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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

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)