La Crosse Dance Centre Online Registration

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Welcome to La Crosse Dance Centre! If you are a new dance artist, we look forward to getting to know you and your family and how we can best serve your needs. If you are a returning artist, welcome back! Our instructors can't wait to connect with you. LET'S DANCE!

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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 (Not Contact #1 or #2)*

Medical conditions to report?

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*

Cell #

Additional Info

Student Email*

School*

Grade Level*

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Attending a TRIAL CLASS?*

Refer NEW Dancer and SAVE $30!

Please fill in the registration form completely. Please let the LDC Office know if you've been referred by a current LDC dance family. And, please reach out to the LDC office with questions: 608-783-5155. nikki@lacrossedancecentre.org

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email*

School*

Grade Level*

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Attending a TRIAL CLASS?*

Refer NEW Dancer and SAVE $30!

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email*

School*

Grade Level*

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Attending a TRIAL CLASS?*

Refer NEW Dancer and SAVE $30!

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email*

School*

Grade Level*

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Attending a TRIAL CLASS?*

Refer NEW Dancer and SAVE $30!

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email*

School*

Grade Level*

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Attending a TRIAL CLASS?*

Refer NEW Dancer and SAVE $30!

Enroll in Classes

Select Class

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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)

Contact #2

How can we contact you?

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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