Studio de danse Danielle Online Registration

Registration

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Merci d'avoir choisi le Studio de danse Danielle! SVP fournir l'information suivante pour les CAMPS. Vous pourrez ensuite effectuer votre choix de camp. Au plaisir de vous rencontrer bientot......................................................................... Thank you for choosing Studio de Danse Danielle! Please provide the information below for CAMPS. You will then be able to choose the camp. We look forward to meeting you soon.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name*

Parents

Nom de l'enfant/Child's Surname Last Name*

Where do you live?

Home Address*

City*

State/Prov*

Postal Code*

Home or Primary Phone*

Additional Info

En cas d'urgence/In case of emergency

# carte assurance maladie/Health Insurance Card #*

Contact #1

Parent # 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

Contact #2

Parent # 2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

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

Difficultes/Disabilites

Allergies (Leave blank if NONE)

Veuillez vous assurer de choisir le bon emplacement (Aylmer/Plateau). Si nous devons modifier votre inscription, nous entrerons en contact avec vous dans les plus brefs delais. Please ensure you choose the appropriate location (Aylmer/Plateau). If we need to modify your registration, we will contact you as soon as possible.

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

Difficultes/Disabilites

Allergies (Leave blank if NONE)

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

Difficultes/Disabilites

Allergies (Leave blank if NONE)

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

Difficultes/Disabilites

Allergies (Leave blank if NONE)

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

Difficultes/Disabilites

Allergies (Leave blank if NONE)

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Acceptation des risques/ Assumption of Risk

Je donne, par la presente, mon consentement a ce que mon enfant, nomme ci-haut, participe aux cours. Je degage Studio de Danse Danielle et ses employes de tout blame et prestations advenant une (des) blessure(s), une perte ou des dommages subi(s) durant la participation a ces activites. J'en assume l'entiere responsabilite.

I hereby give my approval for the above mentioned child to participate in your classes. I assume all risks and hazards incidental to the participation and I do hereby waive the right to any and all claims arising out of an injury, a loss or any damage sustained on the premises or while participating in any activities involving Studio de Danse Danielle or any of its employees.

I've read the above and agree.

Annulation/Cancellation

Toute demande d'annulation doit etre soumise par ecrit, datee et signee par le requerant (les demandes par courriel ne sont pas acceptees). Des frais administratifs de $25.00 par inscription hebdomadaire de camps sont retenus pour chaque demande de remboursement. Aucun remboursement apres le debut du camp.

Any cancellation request must be submitted in writing, dated and signed by the asking party (email requests are not accepted). There is a $25.00 administration fee per weekly camp for every refund request processed. There are no refunds after the start of the camp.

I've read the above and agree.

Photo et/and Video

Je reconnais que toutes les photographies et/ou tous les videos pris(es) par ou pour le Studio de Danse Danielle appartiennent au Studio de Danse Danielle. Studio de Danse Danielle se reserve le droit d'utiliser les photographies et/ou les videos des etudiants ne permettant aucune reclamation contre l'ecole ni le photographe/videographe.

I recognize that any and all photos and/or videos taken by or for the Studio de Danse Danielle become property of the school. The school reserves the right to use pictures and/or videos of students, allowing no claims to be made against the danse school or the photographer/videographer for their 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

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

Country *

City

State/Prov*

Postal Code*