ADA Dance Co Online Registration

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WELCOME TO ADA DANCE CO 2023/2024 DANCE SEASON

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Referral Information

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Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State/Prov*

Postal Code*

Primary Phone*

Additional Info

Emergency Contact Info*

Health Card Number

Contact #1

Contact #1 First Name*

Last Name *

Type*

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Home Phone *

Work #

Cell #

Portal Access (your email is your login)

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Confirm Email*

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Confirm Portal Account Password

Who is your employer?

Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 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

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

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Primary Doctor

Please select from our variety of classes below.

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

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Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

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Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

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Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Please select from our variety of classes below.

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Please select from our variety of classes below.

Enroll in Classes

Select Class *

Add Another Student

Required Policies

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Questions or Concerns

Comments

Payment Information

Please fill out CREDIT CARD Payment Method

Credit Card

Card Number *

Exp Month *

Exp Year *

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Name as it appears on card *

Address Line 1

Address Line 2

Country *

City

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Postal Code*

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Transit # (5-digits)

Institution ID (3-digits)

Account Number

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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)

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)

Additional Info

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Student #4 (Show-Hide Details)

Additional Info

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Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

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Questions or Concerns

Payment Information

Credit Card

eCheck/Bank Draft

Required Policies

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