Champions Gymnastics Center Online Registration

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Welcome to Champions Gymnastics Center! We're excited to have you as a member of the Champions family! If you want your monthly tuition fees to be paid automatically using the payment method you enter, please select an ePayment Schedule. Your account will be processed accordingly every month after the first month of enrollment. For questions and enrollment completion, please call us at 870-236-3286.

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Referral Information

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Family Information

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Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)*

Health Insurance Carrier*

Place of Work - Mother

Place of Work - Father

Contact #1

Contact #1 First Name*

Last Name *

Type*

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Home Phone

Work #

Cell #

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Confirm Email*

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Employer*

Employer Phone*

Employer Notes

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

Who is your employer?

Employer

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Student #1

Student's First Name*

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Student Gender*

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Additional Info

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Primary Doctor

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Primary Doctor

Student #3 (Show-Hide Details)

Student's First Name*

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Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Primary Doctor

Student #4 (Show-Hide Details)

Student's First Name*

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Student Gender*

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

Additional Info

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Primary Doctor

Student #5 (Show-Hide Details)

Student's First Name*

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

Additional Info

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Primary Doctor

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e-Payment Schedule

Please fill out ONE of the following Payment Methods

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Exp Month

Exp Year

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Address Line 1

Address Line 2

City

State

Zip

eCheck/Bank Draft

Bank Name

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Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number

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

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I Agree to All of the Above

Questions or Concerns

Payment Information

Account Information

Credit Card

eCheck/Bank Draft

Required Policies

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