Xpressions Dance Academy Online Registration

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WELCOME TO XPRESSIONS DANCE ACADEMY ONLINE ENROLLMENT!

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Referral Information

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Referral Name*

Account Information

Account (family last name) Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

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

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*

Additional Info

Student Email

Grade Level

Disabilites. Leave blank if none

Special Needs. Leave blank if none

Allergies. Leave blank if none

Medications. Leave blank if none

Immunization Notes

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Grade Level

Disabilites. Leave blank if none

Special Needs. Leave blank if none

Allergies. Leave blank if none

Medications. Leave blank if none

Immunization Notes

SELECT YOUR CLASSES BELOW.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Grade Level

Disabilites. Leave blank if none

Special Needs. Leave blank if none

Allergies. Leave blank if none

Medications. Leave blank if none

Immunization Notes

SELECT YOUR CLASSES BELOW.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Grade Level

Disabilites. Leave blank if none

Special Needs. Leave blank if none

Allergies. Leave blank if none

Medications. Leave blank if none

Immunization Notes

SELECT YOUR CLASSES BELOW.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Grade Level

Disabilites. Leave blank if none

Special Needs. Leave blank if none

Allergies. Leave blank if none

Medications. Leave blank if none

Immunization Notes

SELECT YOUR CLASSES BELOW.

Enroll in Classes

Select Class

Add Another Student

Required Policies

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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

Account Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

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

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Student #4 (Show-Hide Details)

Additional Info

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Student #5 (Show-Hide Details)

Additional Info

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Questions or Concerns

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Credit Card

Required Policies

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