Be Dance With Ms. Reggy Online Registration

Registration

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Welcome to Be Dance! We are excited to dance with you! Please fill in your information below and click Submit when you're done. Note that your Card will NOT be charged at this time. All enrollments are considered pending until we review your registration. Applicable discount will be applied as well. Look out for a Welcome e-mail once your registration has been finalized.

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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)

Contact #1

Adult contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

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

Adult 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

School*

Grade Level

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Please select your class(es) below

Enroll in Classes

Select Another Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School*

Grade Level

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Please select your class(es) below

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School*

Grade Level

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Please select your class(es) below

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School*

Grade Level

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Please select your class(es) below

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School*

Grade Level

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Please select your class(es) below

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

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*

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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

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Account Information

Credit Card

Required Policies

(Show-Hide Details)