Registration Form

please fill out this form or email us your information to get started.

Child Health History

"*" indicates required fields

Child's Name*

First Last

Gender*

Male

Female

Birthday*

Age*

Address*

Street Address Address Line 2 City State ZIP Code

Phone - Home or Cell*

Phone - Work

Email*

Emergency Contact Info

In case of emergency, please notify*

First Last

Emergency Contact Relationship*

Emergency Contact Phone*

Pediatrician Name*

First Last

Pediatrician Phone*

Medical Information

Child Vaccination Status

Yes

No

Please list any medical conditions your child may have that would affect taking part in physical activity.

Date*

I, the parent/guardian of the aforementioned child, acknowledge the above information to be true and accurate. To the best of my knowledge, I have given all relevant information regarding my child’s health and ability to participate safely in an exercise program.*

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212-879-1566

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info@energeticjuniors.com

ENERGETIC JUNIORS

Kids’ Fitness Programs In New York City
Phone: 212-879-1566
Email: info@energeticjuniors.com

Some of the zip codes we service are:
10001, 10003, 10004, 10010, 10012, 10014, 10016, 10019, 10021, 10023, 10024, 10025, 10028, 10033, 10065, 10075, 10128, 10280, 11201, 11205, 11206, 11215.

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