ADA Dance Co Online Registration

Registration

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Welcome to ADA Dance Co

* 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*

Health Card 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

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* (format=dd/mm/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Please select from our variety of classes below.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=dd/mm/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Please select from our variety of classes below.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=dd/mm/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Please select from our variety of classes below.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=dd/mm/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Allergies

Medications

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* (format=dd/mm/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Please select from our variety of classes below.

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Release of Liability

As the legal parent or guardian, I release and hold harmless ADA Dance Co, its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control and supervision of Annemarie's Dance Academy, its owners and operators or in route to or from any of said premises.

I've read the above and agree.

Signature Text

I've read the above and agree.

Medical Emergency

The undersigned gives permission to ADA Dance Co, its owners and operators to seek medical treatment for the participant in the event they are not able to reach a parent or guardian. I hereby declare any physical/mental problems, restictions, or condition and/or declare the paricipant to be in good physical and mental health. I request that our doctor/physician ________________ be called and that my child be transported to ______________________ hospital. Please include physicians' phone number _______________.

I've read the above and agree.

Payment Information

Tuition is due by the tenth of each month. If accounts are paid after the tenth of the month there is an additional amount due according to the length of the class, There is a $35.00 returned cheque charge for any cheques returned by the bank.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments