Studio 4 Online Registration

Registration

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Thank you for taking a few minutes to fill out the registration form below. Please be sure to include as much information as possible to allow us to better serve you. You will receive an email confirmation soon after this is submitted. If you do not receive this please contact Studio 4 at billing@studio4dancers.com.

* 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 (other then contact #1 and #2)*

Health Insurance Company AND Policy #*

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone *

Work #

Cell #

Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Studio 4. 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

Who is your employer?

Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Studio 4. Standard message and data rates apply. Reply STOP to opt out

Email (Emails are kept confidential)

Confirm Email

Who is your employer?

Employer

Employer Phone

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Disabilities*

Special Health Considerations *

Allergies*

Medications*

Primary Doctor AND phone #*

Hospital/Clinic Preference*

Please select the appropriate class(es) below. Studio 4 will do it's best to contact you prior to the class start date in regards to a possible incorrect selection.

Enroll in Classes

Select Another Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Disabilities*

Special Health Considerations *

Allergies*

Medications*

Primary Doctor AND phone #*

Hospital/Clinic Preference*

Please select the appropriate class(es) below. Studio 4 will do it's best to contact you prior to the class start date in regards to a possible incorrect selection.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Disabilities*

Special Health Considerations *

Allergies*

Medications*

Primary Doctor AND phone #*

Hospital/Clinic Preference*

Please select the appropriate class(es) below. Studio 4 will do it's best to contact you prior to the class start date in regards to a possible incorrect selection.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Disabilities*

Special Health Considerations *

Allergies*

Medications*

Primary Doctor AND phone #*

Hospital/Clinic Preference*

Please select the appropriate class(es) below. Studio 4 will do it's best to contact you prior to the class start date in regards to a possible incorrect selection.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Disabilities*

Special Health Considerations *

Allergies*

Medications*

Primary Doctor AND phone #*

Hospital/Clinic Preference*

Please select the appropriate class(es) below. Studio 4 will do it's best to contact you prior to the class start date in regards to a possible incorrect selection.

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule*

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*

Jackrabbit Technologies' class management platform & registration portal is trusted by 1000s of
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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)

Who is your employer?

Contact #2

How can we contact you?

Who is your employer?

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)