Life Moves Dance Studio Online Registration

Registration

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Welcome to Life Moves Dance Studio! We are excited you are here!

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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*

Military/Police/EMT: yes / no*

Photography Release: yes / no*

Teacher: yes / no*

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*

Student Gender*

Birth Date*

Additional Info

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

If you need any help during the registration process, please do not hesitate to contact the office at (912) 756-8482, text (912) 661-4056, or email lifemovesinfo@gmail.com. We will gladly help and guide you through the process and place your dancer in the appropriate class(es). Discounts will be applied after family/child has been signed up for class(es). Discounts are shown on our tuition schedule that can be viewed or downloaded on the Life Moves Dance Studio website at www.lifemovesdance.com.

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Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

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Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

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Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

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Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

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Special Needs (Leave blank if NONE)

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Medications (Leave blank if NONE)

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Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

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Payment Information

Credit Card

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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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