Edge Dance Studios LLC Online Registration

Registration

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* 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

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

Who is your employer?

Employer

Employer Phone

Employer Notes

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

Who is your employer?

Employer

Employer Phone

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Contact Phone Number

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Enroll in Classes

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Contact Phone Number

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Enroll in Classes

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Contact Phone Number

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Enroll in Classes

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Contact Phone Number

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Enroll in Classes

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Contact Phone Number

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Enroll in Classes

Add Another Student

Required Policies and Agreements

PLEASE NOTE:

Your credit card WILL NOT BE CHARGED until Edge Office staff has thoroughly reviewed your class requests, applied the proper multi-class discounts and contacted you via phone to confirm. This process usually takes between 48 and 72 hours.

I've read the above and agree.

Edge Dance Studios LLC Policies & Information

The signature below signifies that I have read a copy of the 2017-2018 Edge policies,
fees (tuition, late fees), rules & regulations, and class attendance information and
agree to all. Including no refunds on classes recital fees and costumes. I also give
permission to auto debit all monthly tuition fees from the account provided.

____________________________________
Signature of Parent or Guardian if student under 18 years of age

I've read the above and agree.

Participation Permission & Acceptance

I understand dance and related activities involve risk of injury. I agree I will not hold Edge Dance
Studios, LLC, (it's owners, staff and related parties) responsible for injuries/damages incurred by
any of my family members while participating or visiting facilities or students participation in any
such activity, whether on or off the premises for such activities, that is connected or associated with
Edge Dance Studios, LLC. This includes, but not limited to rehearsals, performances, competitions,
and/or any classes or activities offered by Edge Dance Studios,LLC.

____________________________________
Signature (Parent or Guardian if student under 18 years of age)

I've read the above and agree.

Authorization of Medical Care

Edge Dance Studios, LLC will always first try to contract the guardian of the student in order to ob-
tain guardians wishes. In the event that the guardian of the student is not available or the stu-
dent is not mentally or verbally capable, the student or the guardian of the student hereby grants
power of attorney to Edge Dance Studios, LLC so that the studio may help in acquiring any reason-
able and/or necessary medical care to the named student. It is understood that edge dance
studios director and staff will use their best efforts to secure medical care for the student. In case
of injury or illness while participating, I authorize medical care for my child and accept responsibility
for medical expenses.

____________________________________
Signature (Parent or Guardian if student under 18 years of age)

I've read the above and agree.

Payment Information

Tuition is due on the first of each month. If accounts are paid after the fifth of the month, there will be a $10.00 late fee applied to the account balance. There is a $25.00 returned check charge for any checks returned by the bank.

I've read the above and agree.

Participation for Use in Media

I allow Edge Dance Studios, LLC to use pictures or videos of my child in advertisements or commercials
to promote the studio. This will be without compensation.

____________________________________
Signature (Parent or Guardian if student under 18 years of age)

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*