Registration
1 openings left in this event!
Already a customer? Click here to login.
Adult Hip Hop with Miss Citra Session runs: Tuesdays 6:45-7:35pm
Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Type
*
Caregiver
Father
Guardian
Mother
Parent
Self
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
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
NE
NC
ND
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
*
Emergency Contact Info (Not Contact #1 or #2)
Students entered below will be added to your family's account
Add New Student #1:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Grade Level:
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Grade Level:
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Grade Level:
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Grade Level:
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Grade Level:
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Questions/Options:
How did you hear about this class?
*
Additional Information:
Waiver/Agreement
(Show-Hide Details)
DANCE & COMPANY – SPECIAL EVENT WAIVER/AGREEMENT
I AM AWARE AND UNDERSTAND THAT I WILL BE PARTICIPATING IN A DANCE/FITNESS PROGRAM WITH DANCE & COMPANY THAT WILL REQUIRE SOME PHYSICAL EXERTION. ALTHOUGH THE MOST COMMON INJURIES OR SYMPTOMS ASSOCIATED WITH EXERCISE INVOLVE SPRAINS, STRAINS, DIZZINESS, FAINTING, AND/OR DISCOMFORT IN BREATH, I RECOGNIZE THAT THERE IS A RISK OF SERIOUS INJURY ASSOCIATED WITH ANY DANCE/FITNESS PROGRAM. I ACKNOWLEDGE THAT ANY INJURIES THAT I SUSTAIN MAY BE COMPOUNDED BY NEGLIGENT EMERGENCY RESPONSE OR RESCUE OPERATIONS OF DANCE & COMPANY. I ACKNOWLEDGE THAT I AM KNOWINGLY AND VOLUNTARILY PARTICIPATING IN THE ACTIVITIES WITH AN EXPRESS UNDERSTANDING OF THE DANGER INVOLVED AND HEREBY AGREE TO ACCEPT AND ASSUME ANY AND ALL RISKS OF INJURY, DEATH, OR PROPERTY DAMAGE, WHETHER CAUSED BY THE ORDINARY NEGLIGENCE OF DANCE & COMPANY, OR OTHERWISE.
Photography/Videography -I understand that Dance & Company has the right to take photos or videos of me (my child) during class, outside related events, or during our Production and post them to our social media accounts, blog and website, as well as for advertising purposes inside and outside of the studio premise. The photos will only be of appropriate nature, related to dance or dance activities.
Furthermore, I understand that while participating in Dance & Company's dance/fitness program Dance & Company employees may need to occasionally physically correct me (or my child) to show proper placement in an exercise/movement which will ultimately help prevent injuries.
I understand that by acknowledging this statement, I (or my child) am agreeing not to hold Dance & Company or any of its employees, owners, agents or insurers responsible for bodily injury that they may suffer as a result of participation in a dance/fitness program through Dance & Company.
I've read the above and agree.
Enter your Full Name:
*
Other Questions/Comments:
Credit Card Verification:
Card Number:
*
Visa
Mastercard
Name as it appears on card:
*
Nickname:
Card Expiration Month:
*
01
02
03
04
05
06
07
08
09
10
11
12
Exp Year:
*
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
2055
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:
*
Please Wait...