Expressions Dance Institute Online Registration

Registration

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Welcome to Expressions Dance Institute! Please complete the following registration form. This will create your account in our system once that is done you will be able to see all classes offered and be able to enroll as well. You will also be able to see and maintain your balance at anytime from anywhere.

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Contact #1

Contact #1 First Name*

Last Name *

How Can We Contact You?

Home Phone

Work #

Cell # *

Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Expressions Dance Institute. Standard message and data rates apply. Reply STOP to opt out

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

How can we contact you?

Home Phone

Work #

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Expressions Dance Institute. Standard message and data rates apply. Reply STOP to opt out

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Expressions Dance Institute. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Expressions Dance Institute. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Expressions Dance Institute. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Expressions Dance Institute. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Expressions Dance Institute. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Account Information

Payment Schedule*

Membership Type*

Credit Card

Card Number

Exp Month

Exp Year

Card Nickname

Name as it appears on card

Address Line 1

Address Line 2

City

State

Zip

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Registration

Referral Information

Family Information

Where do you live?

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Account Information

Credit Card

Required Policies

(Show-Hide Details)