CLASSICAL DANCE ACADEMY Online Registration

Registration

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Welcome to Classical Dance Academy's Registration. Please fill out the information below. Red '*' are required fields. Click Submit when you are done.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name*

Family Information

Students Last Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional Info

Emergency Contact Info. Name/Relationship/Phone Number*

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

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

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Choose any filter to narrow your search.

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

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Choose any filter to narrow your search.

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

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Choose any filter to narrow your search.

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

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Choose any filter to narrow your search.

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

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Choose any filter to narrow your search.

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Waiver, Claim & Release of Liability

The undersigned, by signing this waiver of claim and release of liability, acknowledges that there are certain inherent risks associated with dance, any of which could result in property or bodily damage. These risks include, but not limited to: warm-up, class, rehearsal or performance.

In consideration for the consent and right given to the undersigned to dance with the Classical Dance Academy, and with full understanding of the inherent risks involved, the undersigned does/do, by signing below, expressly assume all risks of any nature whatsoever and does/do hereby release and forever discharge the Classical Dance Academy, their officers, directors, employees and agents, from any claim or liability of property or bodily injury and any nature whatsoever arising out of the Classical Dance Academy operation, and the undersigned does/do acknowledge full and total personal insurance responsibility while participating with the Classical Dance Academy.

The undersigned also agrees with and accepts all policies stated in Classical Dance Academy's Policy handout or found on the website.

I've read the above and agree.

Photo Release

I do hereby authorize Classical Dance Academy and their legal representatives and assigns, the right and permission to publish, without charge, photographs taken during Classical Dance Academy activities. These photographs may be used in publications, including electronic publications, in audio-visual presentations, promotional literature, advertising, or in other similar ways.
I also agree that I will not be compensated for supplying the(se) picture(s) whether published or not.

I've read the above and agree.

Recurring Payment Authorization

I authorize CDA to charge my account on a regularly recurring basis to bring the account listed current.
I agree that no further prior notification will be required unless the date or amount changes.
I agree to be responsible to keep auto payment information on file current.
I understand that this authorization will remain in effect as long as services are being received and account holds a balance.
If the selected payment date falls on a weekend or holiday, I understand that the payments may be executed on the next business day.

For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the selected payment due date. In the case of any transaction being rejected for Non Sufficient Funds (NSF), I understand that CDA may at its discretion attempt to process the charge again within 30 days. I agree to an additional charge of $30 for each attempt returned NSF initiated as a separate transaction from the authorized recurring payment.

I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of the credit card/bank account information provided and will not dispute these scheduled transactions with my bank or credit card company so long as the transactions correspond to the terms indicated.

I've read the above and agree.

Agreement

I do hereby acknowledge that all information entered is true and up-to-date.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule*

Please fill out ONE of the following Payment Methods

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

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number