LaShelle's School of Dance Online Registration

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Thank you for choosing LaShelle's School of Dance! Please complete the form below and select classes.

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Referral Information

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Referral Name

Family Information

Create Account User Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency: Other Than 1st Parent & Their Number*

Parent 1 Social Security #*

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

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

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs*

Allergies*

Medications*

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Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs*

Allergies*

Medications*

Choose any filter to begin viewing available classes.

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs*

Allergies*

Medications*

Choose any filter to begin viewing available classes.

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs*

Allergies*

Medications*

Choose any filter to begin viewing available classes.

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs*

Allergies*

Medications*

Choose any filter to begin viewing available classes.

Enroll in Classes

Select Class *

Add Another Student

Required Policies

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Comments

Payment Information

Account Information

e-Payment Schedule

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

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number

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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)

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Student #4 (Show-Hide Details)

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Student #5 (Show-Hide Details)

Additional Info

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Questions or Concerns

Payment Information

Account Information

Credit Card

eCheck/Bank Draft

Required Policies

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