Coastal Dance Centre Online Registration

Registration

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Registration is required for new and returning students. Returning students may access their account through the Family Portal to register for classes and update their information. (If it is your first time using the portal, please click "I do not know my password" for a password to be sent). If you have questions or concerns regarding registration, please do not hesitate to call us at 843-839-5678 or email: info@coastaldancecentre.com

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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*

Contact #1

Contact #1 First Name*

Last Name *

Relation*

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

Who is your employer?

Employer*

Employer Phone*

Employer Notes

Contact #2

Contact #2 First Name*

Last Name*

Relation*

How can we contact you?

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*

Cell #

Additional Info

Student Email

Academic School*

Academic Grade Level*

Disabilities or Special Needs

Special Needs

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Please be sure to check the studio location when registering for your classes. Classes displayed will be for both location at Market Common on Deville St. and Howard Ave.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

Academic School*

Academic Grade Level*

Disabilities or Special Needs

Special Needs

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Please be sure to check the studio location when registering for your classes. Classes displayed will be for both location at Market Common on Deville St. and Howard Ave.

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

Academic School*

Academic Grade Level*

Disabilities or Special Needs

Special Needs

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Please be sure to check the studio location when registering for your classes. Classes displayed will be for both location at Market Common on Deville St. and Howard Ave.

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

Academic School*

Academic Grade Level*

Disabilities or Special Needs

Special Needs

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Please be sure to check the studio location when registering for your classes. Classes displayed will be for both location at Market Common on Deville St. and Howard Ave.

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

Academic School*

Academic Grade Level*

Disabilities or Special Needs

Special Needs

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Please be sure to check the studio location when registering for your classes. Classes displayed will be for both location at Market Common on Deville St. and Howard Ave.

Enroll in Classes

Select Class *

Add Another Student

Required Policies

(Show-Hide Details)

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

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

Credit Card

Required Policies

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