Encore Dance Center Online Registration

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Welcome to Encore Dance Center's online registration! Please provide your information below and click Submit when complete. Please note: Credit cards are NOT charged at the time of registration.

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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*

Health Insurance Carrier

Contact #1

Contact #1 First Name*

Last Name *

Type*

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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

Who is your employer?

Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 First Name

Last Name

Type

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Home Phone

Work #

Cell #

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

Transportation

Disabilities*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Dance Intro I, II, III Classes - Ages 3-6 Intro Classes - Ages 7-11 Level I Classes - Ages 7-12 Level II Classes - Ages 11-13 Level III Classes - Ages 13+ All Teen/Adult Classes - Ages 14+

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

Transportation

Disabilities*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Dance Intro I, II, III Classes - Ages 3-6 Intro Classes - Ages 7-11 Level I Classes - Ages 7-12 Level II Classes - Ages 11-13 Level III Classes - Ages 13+ All Teen/Adult Classes - Ages 14+

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

Transportation

Disabilities*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Dance Intro I, II, III Classes - Ages 3-6 Intro Classes - Ages 7-11 Level I Classes - Ages 7-12 Level II Classes - Ages 11-13 Level III Classes - Ages 13+ All Teen/Adult Classes - Ages 14+

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

Transportation

Disabilities*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Dance Intro I, II, III Classes - Ages 3-6 Intro Classes - Ages 7-11 Level I Classes - Ages 7-12 Level II Classes - Ages 11-13 Level III Classes - Ages 13+ All Teen/Adult Classes - Ages 14+

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

Transportation

Disabilities*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Dance Intro I, II, III Classes - Ages 3-6 Intro Classes - Ages 7-11 Level I Classes - Ages 7-12 Level II Classes - Ages 11-13 Level III Classes - Ages 13+ All Teen/Adult Classes - Ages 14+

Enroll in Classes

Select Class

Add Another Student

Required Policies

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Questions or Concerns

Comments

Payment Information

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?

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

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Student #2 (Show-Hide Details)

Additional Info

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Student #3 (Show-Hide Details)

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Student #4 (Show-Hide Details)

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Student #5 (Show-Hide Details)

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