NEW HEIGHTS GYM

STUDENT REGISTRATION

Student’s First Name:   ______________________    Student’s Last Name:   _________________________

Class Registering For:   ________________________           Class Day & Time:   _____________________

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

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Father’s Name:   ______________________ Father’s SS #:   ___________   Primary Guardian?   Yes   or    No

Father’s Home Address: _______________________________   Father’s Home Phone:   _______________   

Father’s Cell:   _____________   Father’s Work #:   ______________   Father’s Email:   _________________         

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Mother’s Name:   ______________________ Mother’s SS#:   ____________ Primary Guardian? Yes   or   No

Mother’s Home Address: ______________________________    Mother’s Home Phone:   ______________   

Mother’s Cell:   ____________   Mother’s Work #:   _____________   Mother’s 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 #:   _______________________