Poise Dance, Inc. Online Registration

Registration

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Please complete the following form to register into one of our programs.

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State/Prov*

Postal Code*

Primary Phone*

Additional Info

Emergency Contact Info*

Contact #1

Contact #1 First Name*

Last Name *

Relationship*

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

Relationship

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

Student Email

School

Grade Level

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Should you have any questions regarding registration and payment, please contact us at accounts@poisedance.ca

For inquiries about classes, please contact artisticdirector@poisedance.ca

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

School

Grade Level

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Should you have any questions regarding registration and payment, please contact us at accounts@poisedance.ca

For inquiries about classes, please contact artisticdirector@poisedance.ca

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

School

Grade Level

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Should you have any questions regarding registration and payment, please contact us at accounts@poisedance.ca

For inquiries about classes, please contact artisticdirector@poisedance.ca

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

School

Grade Level

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Should you have any questions regarding registration and payment, please contact us at accounts@poisedance.ca

For inquiries about classes, please contact artisticdirector@poisedance.ca

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

School

Grade Level

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Should you have any questions regarding registration and payment, please contact us at accounts@poisedance.ca

For inquiries about classes, please contact artisticdirector@poisedance.ca

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

Country *

City

State/Prov*

Postal Code*

Jackrabbit Technologies' class management platform & registration portal is trusted by 1000s of
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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

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

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Required Policies (Show-Hide Details)

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Questions or Concerns

Payment Information

Credit Card

Required Policies

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