Registration
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Referral Information
How did you hear about us?
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Coupon
Exhibition
Facebook
Internet Search
Newspaper Ad
Other
Parent Magazine
Performance
Referral
Walk-in
Website
Referral Name
Family Information
Family Name Last Name
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Where do you live?
Home Address
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City
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State
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AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NE
NC
ND
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
VI
Zip
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Primary Phone
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Additional Info
Emergency Contact Info (Not Contact #1 or #2)
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Health Insurance Carrier
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Contact #1
Parent/Guardian First Name
*
Last Name
*
Type
*
Father
Grandparent
Guardian
Mother
Parent
Self
How Can We Contact You?
Home Phone
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Work #
Cell #
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Portal Access (your email is your login)
Email
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(Emails are kept confidential)
Confirm Email
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Portal Account Password
Confirm Portal Account Password
Who is your employer?
Employer
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Employer Phone
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Employer Notes
Contact #2
Parent/Guardian First Name
*
Last Name
*
Type
*
Father
Grandparent
Guardian
Mother
Parent
Self
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
*
Female
Male
Birth Date
*
Additional Info
Student Email
Disabilities (Leave blank if NONE)
Student #2
(Show-Hide Details)
Student's First Name
Last Name
Student Gender
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Female
Male
Birth Date
*
Additional Info
Student Email
Disabilities (Leave blank if NONE)
Student #3
(Show-Hide Details)
Student's First Name
Last Name
Student Gender
*
Female
Male
Birth Date
*
Additional Info
Student Email
Disabilities (Leave blank if NONE)
Student #4
(Show-Hide Details)
Student's First Name
Last Name
Student Gender
*
Female
Male
Birth Date
*
Additional Info
Student Email
Disabilities (Leave blank if NONE)
Student #5
(Show-Hide Details)
Student's First Name
Last Name
Student Gender
*
Female
Male
Birth Date
*
Additional Info
Student Email
Disabilities (Leave blank if NONE)
Add Another Student
Required Policies
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I Agree to All of the Above
Enter your Full Name
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April 16, 2025
Questions or Concerns
Comments
Payment Information
Account Information
e-Payment Schedule
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AUTO 1st of the Month
AUTO Annual
AUTO Semi Annual
Membership Type
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Annually
Monthly
On-Line
Semi-Annually
Please fill out CREDIT CARD Payment Method
Credit Card
Card Number
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Visa
Mastercard
Amex
Discover
Exp Month
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01
02
03
04
05
06
07
08
09
10
11
12
Exp Year
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Card Nickname
Name as it appears on card
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Address Line 1
Address Line 2
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
VI
Zip
*
eCheck/Bank Draft
Bank Name
Account Type
Checking
Savings
Your Account Name
(Your name on your bank statement)
Bank Routing Number
(9-digit number)
Account Number
Jackrabbit Technologies' class management platform & registration portal is trusted by 1000s of
dance studios
,
gyms
,
swim schools
,
music schools
,
cheer gyms
,
childcare centers
, and
more
.
