Great South Bay Dance Center Online Registration

Registration

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Welcome to Great South Bay Dance! We are dedicated to teaching a diverse, curriculum-based dance program to students of all ages in a non-competitive atmosphere. With emphasis on disciplined technique as well as fun, we encourage students to challenge themselves while dancing from their hearts.

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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*

Permission to text you?*

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # * Receive Text Message Notifications

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 # * Receive Text Message Notifications

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

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

Cell # Receive Text Message Notifications

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell # Receive Text Message Notifications

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell # Receive Text Message Notifications

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell # Receive Text Message Notifications

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell # Receive Text Message Notifications

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

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 Great South Bay Dance LLC, 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 Great South Bay Dance LLC, its owners and operators or in route to or from any of said premises.

I've read the above and agree.

Photo Release

I hereby grant Great South Bay Dance LLC, its owners and operators the right to photograph the participant and use photos and/or other digital reproductions of her/him for promotional purposes, whether print, digital, or electronic publishing.

I've read the above and agree.

Medical Emergency

The undersigned gives permission to Great South Bay Dance LLC, 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, restrictions, or condition and/or declare the participant to be in good physical and mental health.

I've read the above and agree.

Payment Information

The credit card or debit card submitted during registration will be processes for Summer tuition in the next 1-3 business days. For more information or concerns, contact us at (631) 598-7100 during regular business hours, or send and email to frontdesk@gsbdance.com

For Fall tuition the credit card or debit card submitted during registration will be processed in the next 1-3 business days for September tuition, June tuition, and the registration fee. (If registering after September, the credit card
or debit card submitted during registration will be processed in the next 1-3 business days for the first month's tuition, June's tuition, and the registration fee.) For more information or questions, contact us at (631)
598-7100 during regular business hours, or send and email to
frontdesk@gsbdance.com.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

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*