Cary Dance Productions Online Registration

Registration

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Online registration requires a credit card and email address. Charges will be posted to your card after your registration has been reviewed, and discounts applied if applicable and payment will be processed soon after. If you cannot supply this information or, have questions before registering, please call the studio at 919.467.7040 or send an email with questions to info@carydance.com

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Referral Information

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Referral Name

Family Information

Family Last Name*

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Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

Health Insurance Carrier

Contact #1

Contact #1 First Name*

Last Name *

Type*

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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*

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level*

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

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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)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

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Student #3 (Show-Hide Details)

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Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

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Grade Level*

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Medications (Leave blank if NONE)

Primary Doctor

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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)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

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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)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

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Select Class

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Card Number

Exp Month

Exp Year

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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

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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

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Student #2 (Show-Hide Details)

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