Act Alive Academy Online Registration

Registration

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Welcome to Act Alive Academy! We are so excited that you will be joining for classes. Please complete the following registration form to hold your place in class. We are thrilled you in the Act Alive Community and we can't wait to see you in class!

* 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*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)

Health Insurance Carrier

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # *

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

Type

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Birth Date*

Additional Info

T-Shirt Size*

School

Grade Level

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)

Primary Doctor

Please click on the Search button below, then choose the class. A one time registration fee applies per student, and includes and Act Alive Academy t-shirt to wear to classes and special events.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

T-Shirt Size*

School

Grade Level

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)

Primary Doctor

Please click on the Search button below, then choose the class. A one time registration fee applies per student, and includes and Act Alive Academy t-shirt to wear to classes and special events.

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

T-Shirt Size*

School

Grade Level

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)

Primary Doctor

Please click on the Search button below, then choose the class. A one time registration fee applies per student, and includes and Act Alive Academy t-shirt to wear to classes and special events.

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

T-Shirt Size*

School

Grade Level

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)

Primary Doctor

Please click on the Search button below, then choose the class. A one time registration fee applies per student, and includes and Act Alive Academy t-shirt to wear to classes and special events.

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

T-Shirt Size*

School

Grade Level

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)

Primary Doctor

Please click on the Search button below, then choose the class. A one time registration fee applies per student, and includes and Act Alive Academy t-shirt to wear to classes and special events.

Enroll in Classes

Select Class *

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

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Registration

Referral Information

Family Information

Where do you live?

Additional Info

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

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Required Policies

(Show-Hide Details)