My Account

 

Working With:
  • Each participant must have his/her own individual account.
  • Please make sure to create an account for each family member before completing a registration.
  • You must select the proper participant at the time of registration.

* Indicates Required Information

*First Name:
Middle Name:
*Last Name:
* Gender:
* Age Group:
Birth Date: (mm/dd/yyyy)
Disability:
*Address:
*City:
*State:
*Zip Code:
Municipality:
Resident:
(Within School District)
*Primary
Phone:
(Enter Only Numbers, Including Area Code)
Cell Phone:
Work Phone:
*E-mail:
2nd E-mail:
Your Email:

Registration confirmations and payment receipts are automatically sent when an e-mail address is provided. Your e-mail address will not be provided to any outside organization and is used only to send messages to you regarding program offerings and your account.

Check here if you choose not to receive email Marketing announcements. You will continue to receive email confirmations.

For many programs, additional information is required. Please provide as much information as possible. For children under the age of 18, the following information is required.

Grade: In School Year: 2015-2016
School:

Parent Guardian 1

First Name:
Last Name:
Role:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Pager:

Parent Guardian 2

First Name:
Last Name:
Role:
Address:
City:
State:
Zip:
Primary Phone:
Work Phone:
Cellular:
Pager:
Disability Information:
Severity:
Wheelchair:
Walker:
Seizures:
Group Home Name:
Group Home Contact:
Group Home Phone:

Additional Contact

Name:
Phone:

Student Contact

Email:
Phone:

Emergency Contact 1

First Name:
Last Name:
Role:
Home Phone:
Mobile Phone:

Emergency Contact 2

First Name:
Last Name:
Role:
Home Phone:
Mobile Phone:

Personal

Height: (X ft XX in)
Weight: lbs.
Date of Immunizations
On File:

Date of Last Physical:

Not on file

Date of Concussion Baseline Test:

Insurance

Carrier:
Policy:

Providers

Clinic Name:
Clinic Phone:
Doctor Name:
Doctor Phone:
Preferred Hospital:
Dentist Name:
Dentist Phone:

History

Medical Concerns:
Current Medications:
Allergies:
Chronic Illnesses:
Previous Conditions: