Academy of Ballet Online Registration

Registration

Las Cruces School of Dance and Music NEW STUDENT REGISTRATION FORM------- Returning Students Re-register in Person or Call the Office 525-5670...........

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Referral Information

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Referral Name*

Family Information

Family Last Name*

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Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

Health Insurance Carrier

Contact #1

Contact #1 First Name*

Last Name *

Type*

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Home Phone *

Work #

Cell #

Email* (Emails are kept confidential)

Confirm Email*

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*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Enrollment for any classes other than "Beginning" will be subject to instructor approval. Students may be placed in a lower or higher level class at the discreation of the instructor.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Enrollment for any classes other than "Beginning" will be subject to instructor approval. Students may be placed in a lower or higher level class at the discreation of the instructor.

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Enrollment for any classes other than "Beginning" will be subject to instructor approval. Students may be placed in a lower or higher level class at the discreation of the instructor.

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Enrollment for any classes other than "Beginning" will be subject to instructor approval. Students may be placed in a lower or higher level class at the discreation of the instructor.

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Enrollment for any classes other than "Beginning" will be subject to instructor approval. Students may be placed in a lower or higher level class at the discreation of the instructor.

Enroll in Classes

Select Class *

Add Another Student

Required Policies

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Comments

Payment Information

Account Information

Membership Type*

eCheck/Bank Draft

Bank Name *

Account Type *

Your Account Name * (Your name on your bank statement)

Bank Routing Number * (9-digit number)

Account Number *

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

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)

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Student #4 (Show-Hide Details)

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Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

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I Agree to All of the Above

Questions or Concerns

Payment Information

Account Information

eCheck/Bank Draft

Required Policies

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