The Dance Factory 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

Student Email

School

Grade Level

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

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

Special Needs

Allergies

Medications

Primary Doctor

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

Special Needs

Allergies

Medications

Primary Doctor

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

Special Needs

Allergies

Medications

Primary Doctor

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

Special Needs

Allergies

Medications

Primary Doctor

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Assumption of Risk

In attending The Dance Factory dance studio/program, taking dance music or excercise classes and otherwise using the facilities and equipment therein, I do so at my own risk. I assume full responsibility for any injuries or damages which may occur to me in, on or about the dance studio/program.

I've read the above and agree.

Release of Liability

The Dance Factory shall not be liable for any damages arising from personal injuries incurred by me in, on or about the premises of The Dance Factory dance studio/program relative to my attendance at the dance studio, taking dance, music or exercise classes or otherwise using the facilities and equipment therin. I do hereby fully and forever release and discharge The Dance Factory, its shareholders, directors, officers, dance instructors, employees and agents from any and all claims, demands, damages, rights of action or causes of action, present or future, whether the same be known, anticipated or unanticipated, resulting from or arising out of my use of said The Dance Factory dance studio/program, dance classes, facilities and equipment thereof. I certify that I/my child is in good health and capable of participating in class and school activities.

I've read the above and agree.

Payment Policies

I understand that I am responsible for tuition payments as described. Automatic debit from credit/debit card or checking/savings account is the only accepted form of payment. Cash or check payments are not accepted. Registration is not valid if account information is not provided. Tuition is quoted on a monthly basis of 10 (10) equal monthly payments, September through June Tuition is due on the first day of each month. Tuition is non-refundable. If your payment is rejected for any reason, (ie. expired card, NSF, card lost) you will be charged a $25.00 service fee. It is your responsibility to notify the office if your card has expired, is lost,stolen or has fraudulant activity.

I've read the above and agree.

Permission

I hereby give permission to The Dance Factory to take and use photographs for promotional use.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule

Membership Type

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