5678 Dance Studio Inc Online Registration

Registration

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Thank you for registering with 5678 Dance Studio! We’re excited to have your dancer join us and look forward to helping them “Dance the Dream.” Tuition will be charged on the first of the month in which your program begins. Please note, if there is a remaining account balance, a late fee will be posted on the 6th of that month. Feel free to reach out with any questions—we’re happy to help!

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Referral Information

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Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State *

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

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

Contact #2

Contact #2 First Name

Last Name

Type

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Work #

Cell # *

Email* (Emails are kept confidential)

Confirm Email*

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)*

Please note that the credit card you submitted during registration is not automatically charged until the 1st of each month.

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)*

Please note that the credit card you submitted during registration is not automatically charged until the 1st of each month.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)*

Please note that the credit card you submitted during registration is not automatically charged until the 1st of each month.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)*

Please note that the credit card you submitted during registration is not automatically charged until the 1st of each month.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)*

Please note that the credit card you submitted during registration is not automatically charged until the 1st of each month.

Enroll in Classes

Select Class

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Comments

Payment Information

Account Information

e-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?

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

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