Powell Dance Academy Online Registration

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Referral Information

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Referral Name

Family Information

Family Last Name*

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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 *

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Cell # * Receive Text Message Notifications

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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

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Home Phone

Work #

Cell # * Receive Text Message Notifications

Email (Emails are kept confidential)

Confirm Email

Who is your employer?

Employer

Employer Phone

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications

Additional Info

Student Email

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications

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Student Email

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Special Needs (Leave blank if NONE)

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Student #3 (Show-Hide Details)

Student's First Name*

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Student Email

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Student #4 (Show-Hide Details)

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Birth Date*

Cell # Receive Text Message Notifications

Additional Info

Student Email

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

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Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications

Additional Info

Student Email

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

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Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

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Zip*

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Registration

Referral Information

Family Information

Where do you live?

Additional Info

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?

Who is your employer?

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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