Broadway Dance West 65th Street Online Registration

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Welcome and thank you for choosing Broadway Dance Center's Children and Teens! Please fill in all fields and then click "Submit Registration Information" to complete registration.

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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*

Below for CAMPERS ONLY:*

CAMP-Pay Deposit Only? (y/n)*

CAMP-Pay In Full? (y/n)*

Contact #1

Parent/Guardian 1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # * Receive Text Message Notifications

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Parent/Guardian 2 First Name

Last Name

Type

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Home Phone

Work #

Cell # * Receive Text Message Notifications

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

New Student (y/n)*

Student Pronouns

Texting Policies for Broadway Dance Center Children & Teens

By selecting the box "Receive Text Message Notifications" on this form, you are agreeing to our Informed Consent for Text (SMS) Messaging terms, conditions and privacy policy, which can be found HERE.

You will give consent to Broadway Dance Center Children & Teens to send occasional text messages regarding class changes, business closings, upcoming events, and account notifications.

If you have questions, please call us at +1 (212) 457-0035.

For help, reply HELP. Reply STOP to unsubscribe.

Standard messages and data rates may apply.

Please consider adding Broadway Dance Center Children & Teens and Number, +1 (212) 457-0035 as a contact, so that our messages will not go to spam.

No mobile information will be shared with third parties/affiliates for marketing/promotional purposes or for any other reason.

Select all classes in which your student would like to enroll.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

New Student (y/n)*

Student Pronouns

Texting Policies for Broadway Dance Center Children & Teens

You will give consent to Broadway Dance Center Children & Teens to send occasional text messages regarding class changes, business closings, upcoming events, and account notifications.

If you have questions, please call us at +1 (212) 457-0035.

For help, reply HELP. Reply STOP to unsubscribe.

Standard messages and data rates may apply.

Please consider adding Broadway Dance Center Children & Teens and Number, +1 (212) 457-0035 as a contact, so that our messages will not go to spam.

No mobile information will be shared with third parties/affiliates for marketing/promotional purposes or for any other reason.

Select all classes in which your student would like to enroll.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

New Student (y/n)*

Student Pronouns

Texting Policies for Broadway Dance Center Children & Teens

You will give consent to Broadway Dance Center Children & Teens to send occasional text messages regarding class changes, business closings, upcoming events, and account notifications.

If you have questions, please call us at +1 (212) 457-0035.

For help, reply HELP. Reply STOP to unsubscribe.

Standard messages and data rates may apply.

Please consider adding Broadway Dance Center Children & Teens and Number, +1 (212) 457-0035 as a contact, so that our messages will not go to spam.

No mobile information will be shared with third parties/affiliates for marketing/promotional purposes or for any other reason.

Select all classes in which your student would like to enroll.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

New Student (y/n)*

Student Pronouns

Texting Policies for Broadway Dance Center Children & Teens

You will give consent to Broadway Dance Center Children & Teens to send occasional text messages regarding class changes, business closings, upcoming events, and account notifications.

If you have questions, please call us at +1 (212) 457-0035.

For help, reply HELP. Reply STOP to unsubscribe.

Standard messages and data rates may apply.

Please consider adding Broadway Dance Center Children & Teens and Number, +1 (212) 457-0035 as a contact, so that our messages will not go to spam.

No mobile information will be shared with third parties/affiliates for marketing/promotional purposes or for any other reason.

Select all classes in which your student would like to enroll.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

New Student (y/n)*

Student Pronouns

Texting Policies for Broadway Dance Center Children & Teens

You will give consent to Broadway Dance Center Children & Teens to send occasional text messages regarding class changes, business closings, upcoming events, and account notifications.

If you have questions, please call us at +1 (212) 457-0035.

For help, reply HELP. Reply STOP to unsubscribe.

Standard messages and data rates may apply.

Please consider adding Broadway Dance Center Children & Teens and Number, +1 (212) 457-0035 as a contact, so that our messages will not go to spam.

No mobile information will be shared with third parties/affiliates for marketing/promotional purposes or for any other reason.

Select all classes in which your student would like to enroll.

Enroll in Classes

Select Class

Add Another Student

Required Policies

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Comments

Payment Information

Account Information

Auto-Payment Schedule*

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

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Contact #1

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Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

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