Registration Form

NEW HEIGHTS GYM

STUDENT REGISTRATION

 

Studentís First Name: ______________________   Studentís Last Name:  _________________________

 

Class Registering For: ________________________           Class Day & Time:  _____________________

 

Age:  ___________    Sex: _________   Birthday:  ______________    Grade: _____________________

 

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Fatherís Name: ______________________ Fatherís SS #: ___________  Primary Guardian?  Yes  or   No

 

Fatherís Home Address: _______________________________  Fatherís Home Phone:  _______________  

 

Fatherís Cell: _____________  Fatherís Work #:  ______________  Fatherís Email:  _________________        

 

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Motherís Name: ______________________ Motherís SS#: ____________ Primary Guardian? Yes  or  No

 

Motherís Home Address: ______________________________   Motherís Home Phone:  ______________  

 

Motherís Cell: ____________  Motherís Work #:  _____________  Motherís Email:  _________________

 

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Emergency Contact Name: _________________________ Emergency #s:  __________________________

 

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PAYMENT INFORMATION

 

Credit Card Type:__________ CC #:________________ Exp:_________  CVV:______  Zip:_________

 

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MEDICAL INFORMATION

 

List any physical handicaps (specify bodily part, weaknesses, etc.):  _______________________________

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List any chronic ailments (asthma, heart problems, diabetes, epilepsy, hemophilia, etc.):  ______________

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List any psychological handicaps (anxiety, fear, hyperactivity, hypersensitivity, etc.): ________________

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List any allergies: ______________________________________________________________________

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Insurance Company: _______________________________           Policy #:  _______________________