DanceRoots Online Registration

Registration

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Welcome to the DanceRoots online registration portal. Please fill out this form to set up your family account.

* 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/Prov*

Postal Code*

Home or Primary Phone*

Additional Info

Emergency Contact Info*

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

Contact #2

Contact #2 First Name

Last Name

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

Student Email

School

Disabilites

Special Needs

Allergies

Medications

Please use the 'Search' button to select a class.....

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

Disabilites

Special Needs

Allergies

Medications

Please use the 'Search' button to select a class.....

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

Disabilites

Special Needs

Allergies

Medications

Please use the 'Search' button to select a class.....

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

Disabilites

Special Needs

Allergies

Medications

Please use the 'Search' button to select a class.....

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

Disabilites

Special Needs

Allergies

Medications

Please use the 'Search' button to select a class.....

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Release Form: Injury

I realize that there are risks involved in any activity or program and I acknowledge that my choice to participate or register my child/self with DanceRoots brings with it assumptions of those risks. I am aware of no physical or other reason why the named student should not participate in this activity. I do hereby release DanceRoots and its employees and agents from fault for injuries due to participation in this activity or in any facility or location that this activity is held. Further, DanceRoots will not be held liable for loss of articles.

I've read the above and agree.

Policies

I have read and agree to the policies as set out by DanceRoots. Our policies can be found at www.danceroots.ca --> Key Info --> 2018/2019 Studio Policies

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

City

State/Prov

Postal Code