D'ansa Jazz Stage Online Registration

Registration

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Welcome! This registration form is the beginning of your process to either register as a student or try classes. Important: a payment method is required upon registration. This card will only be charged if you make it your default payment method, but otherwise, it works as a deposit/ or card for pending balances. Pending balances could be any previous charges you agreed on, that haven't been cleared. This card on file can be removed or changed at any time, and upon withdrawal of classes.

* 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*

Primary Phone*

Additional Info

Emergency Contact Info*

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Cell # *

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?

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

STUDENT EMAIL(Leave blank if NONE)

T-Shirt Size*

School*

Grade Level*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

STUDENT EMAIL(Leave blank if NONE)

T-Shirt Size*

School*

Grade Level*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

STUDENT EMAIL(Leave blank if NONE)

T-Shirt Size*

School*

Grade Level*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

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(Leave blank if NONE)

T-Shirt Size*

School*

Grade Level*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

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(Leave blank if NONE)

T-Shirt Size*

School*

Grade Level*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

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*

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)

Contact #2

How can we contact you?

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)