Cabot Dance Academy Online Registration

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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

Contact #1

Contact #1 First Name*

Last Name *

Type*

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Home Phone

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Contact #2

Contact #2 First Name

Last Name

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Home Phone

Work #

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Email (Emails are kept confidential)

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Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

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Medications (Leave blank if NONE)

Primary Doctor

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Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

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Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

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Medications (Leave blank if NONE)

Primary Doctor

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Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

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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*

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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)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

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Student #3 (Show-Hide Details)

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