Phusion Performing Arts Alliance Online Registration

Registration

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WELCOME TO PHUSION!

We are thrilled you have made the choice to become a part of our Phusion Family and applaud you for selecting a dance program which will surely be a life enhancing experience for your student.

Registration Fee is $55 per student and is due at time of registration. Registration fee is non-refundable and non-transferrable. If you experience issues with registering, please email admin@phusiondance.net.

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Referral Information

How did you hear about us?*

Referral Name*

Family Information

Family Name / Acct Last Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

Health Insurance Carrier*

Cell Phone Carrier for TEXTING*

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*

Cell #

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Transportation

Disabilities*

Special Needs (Leave blank if NONE)

Allergies*

Medications*

Primary Doctor*

Authorized Pick-Up Contact

Phusion offers a number of different dance programs for individuals of all ages.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Transportation

Disabilities*

Special Needs (Leave blank if NONE)

Allergies*

Medications*

Primary Doctor*

Authorized Pick-Up Contact

Phusion offers a number of different dance programs for individuals of all ages.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Transportation

Disabilities*

Special Needs (Leave blank if NONE)

Allergies*

Medications*

Primary Doctor*

Authorized Pick-Up Contact

Phusion offers a number of different dance programs for individuals of all ages.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Transportation

Disabilities*

Special Needs (Leave blank if NONE)

Allergies*

Medications*

Primary Doctor*

Authorized Pick-Up Contact

Phusion offers a number of different dance programs for individuals of all ages.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Transportation

Disabilities*

Special Needs (Leave blank if NONE)

Allergies*

Medications*

Primary Doctor*

Authorized Pick-Up Contact

Phusion offers a number of different dance programs for individuals of all ages.

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

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*

Jackrabbit Technologies' class management platform & registration portal is trusted by 1000s of
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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

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies

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