Registration
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This open gym is for all ages (children will be separated by age for safety)! Whether looking for 1 hour child care while you run errands or work out or would just like to stay and watch your child play we are here for you! Children under 5 who are being dropped off must be pottied/changed at drop off time.
Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
- denotes required fields
Family & Contact Information
First Name:
*
Last Name:
*
Relationship
*
Father
Grandparent
Guardian
Mother
Other
Parent
Step Father
Step Mother
Home Phone:
*
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
*
State:
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NE
NC
ND
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
*
Emergency Contact Name and Number
*
Students entered below will be added to your family's account
Add New Student #1:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
What do you expect your child to get out of our program?:
Medical Conditions/ Disabilities:
*
Allergies/Sensitivities:
*
List and explain any medications/devices you or your child will have on hand during class:
*
Any history of head injuries, broken bones, sprains, fainting, seizures, etc?:
*
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
What do you expect your child to get out of our program?:
Medical Conditions/ Disabilities:
*
Allergies/Sensitivities:
*
List and explain any medications/devices you or your child will have on hand during class:
*
Any history of head injuries, broken bones, sprains, fainting, seizures, etc?:
*
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
What do you expect your child to get out of our program?:
Medical Conditions/ Disabilities:
*
Allergies/Sensitivities:
*
List and explain any medications/devices you or your child will have on hand during class:
*
Any history of head injuries, broken bones, sprains, fainting, seizures, etc?:
*
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
What do you expect your child to get out of our program?:
Medical Conditions/ Disabilities:
*
Allergies/Sensitivities:
*
List and explain any medications/devices you or your child will have on hand during class:
*
Any history of head injuries, broken bones, sprains, fainting, seizures, etc?:
*
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
What do you expect your child to get out of our program?:
Medical Conditions/ Disabilities:
*
Allergies/Sensitivities:
*
List and explain any medications/devices you or your child will have on hand during class:
*
Any history of head injuries, broken bones, sprains, fainting, seizures, etc?:
*
Additional Information:
Other Questions/Comments:
Credit Card Verification:
Card Number:
*
Visa
Mastercard
Discover
Name as it appears on card:
*
Nickname:
Card Expiration Month:
*
01
02
03
04
05
06
07
08
09
10
11
12
Exp Year:
*
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
Address Line 1:
Address Line 2:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
VI
Zip:
*
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