Bridgets Dance Studio Online Registration

Registration

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Bridget's Dance Studio Registration Form 2022 - 2023

* 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*

Zip*

Home or Primary Phone*

Additional Info

Emergency Contact Info*

Health Insurance Carrier*

Contact #1

Parents First Name*

Last Name *

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

Student #1

Student's First Name*

Last Name*

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

Cell #*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications*

Primary Doctor*

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

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

Cell #*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications*

Primary Doctor*

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

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

Cell #*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications*

Primary Doctor*

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

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

Cell #*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications*

Primary Doctor*

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

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

Cell #*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications*

Primary Doctor*

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

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

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)

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies

(Show-Hide Details)