Dance by Design Studios Online Registration

Registration

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Welcome to Dance by Design Studio's registration page! Please fill out the information below and click submit when complete. Your credit card will be charged once your registration has been approved.

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Referral Information

How did you hear about us?*

Referral Name

Contact Information

Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Alternative Emergency Contact Info

Health Insurance Carrier

Enter Promo Code

Why did you choose us?

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # * Receive Text Message Notifications

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 # Receive Text Message Notifications

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications

Additional Info

Student Email

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Choose any filter to begin viewing available classes

Enroll in Classes

Select Another Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications

Additional Info

Student Email

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Choose any filter to begin viewing available classes

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications

Additional Info

Student Email

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Choose any filter to begin viewing available classes

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications

Additional Info

Student Email

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Choose any filter to begin viewing available classes

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications

Additional Info

Student Email

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Choose any filter to begin viewing available classes

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Account Information

How I plan to pay*

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

Contact 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

Payment Information

Account Information

Credit Card

Required Policies

(Show-Hide Details)