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:   __________________________

 

 

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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List any other medical problems:   __________________________________________________________

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Insurance Company:   _______________________________            Policy #:   _______________________