Lana's Dance Centre,LLC Online Registration

Registration

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Welcome to Lana's Dance Centre ,LLC "Where Quality Dancers Turnout Better" We are excited to have you join us! We've made it easier and more convenient for you to enroll your dancer. Please complete the following registration form. Thank you for choosing Lana's Dance Centre, LLC

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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*

Contact #1

Contact #1 First Name*

Last Name *

Type*

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

Who is your employer?

Employer*

Employer Phone*

Employer Notes

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*

Cell #

Additional Info

Student Email

T-Shirt Size*

Grade Level*

Disabilities (If not any write NONE )*

Special Needs (If not any write NONE)*

Allergies ( If not any write NONE)*

Medications (If not any write NONE )*

Primary Doctor*

Dance Exp (Subject: Length ) *

Dancer Lives with*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size*

Grade Level*

Disabilities (If not any write NONE )*

Special Needs (If not any write NONE)*

Allergies ( If not any write NONE)*

Medications (If not any write NONE )*

Primary Doctor*

Dance Exp (Subject: Length ) *

Dancer Lives with*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size*

Grade Level*

Disabilities (If not any write NONE )*

Special Needs (If not any write NONE)*

Allergies ( If not any write NONE)*

Medications (If not any write NONE )*

Primary Doctor*

Dance Exp (Subject: Length ) *

Dancer Lives with*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size*

Grade Level*

Disabilities (If not any write NONE )*

Special Needs (If not any write NONE)*

Allergies ( If not any write NONE)*

Medications (If not any write NONE )*

Primary Doctor*

Dance Exp (Subject: Length ) *

Dancer Lives with*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size*

Grade Level*

Disabilities (If not any write NONE )*

Special Needs (If not any write NONE)*

Allergies ( If not any write NONE)*

Medications (If not any write NONE )*

Primary Doctor*

Dance Exp (Subject: Length ) *

Dancer Lives with*

Please click on the Search button below, then choose the class.

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

City

State

Zip*

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Registration

Referral Information

Family Information

Where do you live?

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Who is your employer?

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

Credit Card

Required Policies

(Show-Hide Details)