Registration
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Come dance with us! Classes are held on Friday nights at 7 pm. This session will be focused on Cha Cha and Waltz styles. Beginners welcome!
Event:
Start Date/Time:
End Date/Time:
Fee per Family:
Room:
*
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Family Information
First Name:
*
Last Name:
*
Type
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Doctor/Physician
Father
Grandparent
Guardian
Mother
Other
Parent
Self
Spouse
Step Father
Step Mother
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
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City:
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State:
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Zip:
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Emergency Contact Info
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Add New Student #1:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email (Leave blank if NONE):
School (Leave blank if NONE):
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email (Leave blank if NONE):
School (Leave blank if NONE):
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email (Leave blank if NONE):
School (Leave blank if NONE):
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email (Leave blank if NONE):
School (Leave blank if NONE):
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
:
Add New Student #5:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email (Leave blank if NONE):
School (Leave blank if NONE):
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
:
Additional Information:
Release of Liability
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I understand that there are inherent risks associated with dancing and related activities, and I understand it is my responsibility (and not the responsibility of Dance Tech Academy) to maintain medical insurance for myself or my minor student while enrolled at Dance Tech. I agree to release Dance Tech, and all Dance Tech instructors and personnel from responsibility of personal injury, loss of property, and all other hazards that may occur while participating in activities related in any way to their association with Dance Tech. I also authorize Dance Tech Academy to obtain emergency treatment for myself or my child if I / they are injured or become ill during said activity. I waive the right to any legal action for any injury sustained on Academy property resulting from normal dance, tumbling or any other activity conducted by the students before, during or after class time.
I've read the above and agree.
Payment Policy
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Payments for the class will be charged at the time of enrollment from the payment source entered by the customer. No refunds will be given for missed classes. If DTA must cancel a class for any reason, a makeup class will be given.
I've read the above and agree.
Enter your Full Name:
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Other Questions/Comments:
Credit Card Verification:
Card Number:
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Name as it appears on card:
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Card Expiration Month:
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Exp Year:
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Address Line 1:
Address Line 2:
City:
State:
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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
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RI
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TN
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UT
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Zip:
*
eCheck/Bank Draft:
Bank Name:
Bank Routing Number:
(9-digit number)
Your Account Name:
(Your name on your bank statement)
Your Account Type:
Checking
Savings
Account Number:
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