Arts in Motion, LLC Online Registration

Registration

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Welcome to the Arts in Motion Family! Arts in Motion Dance Studio 6175 Jackson Rd. Suite B Ann Arbor, MI 48103

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name*

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional Info

Emergency Contact Info*

Health Insurance Carrier

Preferred Physician

Physician Phone

Preferred Hospital

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # Receive Text Message Notifications

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 # Receive Text Message Notifications

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Any discounts for multiple classes/students will be applied to your account after registration is complete.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Any discounts for multiple classes/students will be applied to your account after registration is complete.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Any discounts for multiple classes/students will be applied to your account after registration is complete.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Any discounts for multiple classes/students will be applied to your account after registration is complete.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Any discounts for multiple classes/students will be applied to your account after registration is complete.

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Release of Liability

As the legal parent or guardian, I recognize the necessity of occasional physical contact with instructors and the risks of illness and injury inherent in any dance program. I am participating upon the express agreement and understanding that I hereby release and hold harmless Arts in Motion, its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control and supervision of Arts in Motion, its owners and operators or in route to or from any of said premises.

I've read the above and agree.

Medical Emergency

The undersigned gives permission to Arts in Motion, its owners and operators to seek medical treatment for the participant in the event they are not able to reach a parent or guardian. I hereby declare any physical/mental problems, restrictions, or conditions and/or declare the participant to be in good physical and mental health. I request that our doctor/physician listed on our registration form be called and that my child be transported to the hospital indicated on that form.

I've read the above and agree.

Payment Information

A non-refundable registration fee of $25 is due at time of registration (no registration fee for FREE TRIALS until enrollment is confirmed) and is good for one calendar year. A minimum commitment of one month is required for Dance Students. Tuition is due by the first class period of each 4 week period (dates will be provided at the beginning of each session). Families will receive an electronic statement the day before the tuition is processed. There is a $30.00 returned check charge for any checks returned by the bank. Withdrawal notification must be given to the office staff in person, on or before the last class period of the month, otherwise tuition for the following month will be processed. No refunds will be processed mid-month.

I've read the above and agree.

Signature Text

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

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

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number