Becky's Academy of Dance Inc. Online Registration

Registration

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Becky's Academy of Dance Web Registration

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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

Health Insurance Carrier

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=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level*

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Registration Fee is $35 and will be charged at time of registration and billed to credit card on file. Children's Academy class fees are $60 per month for a hour class once a week or $72 per month for an hour and a half class once a week. All Adult Classes purchase class card from Becky's during office hours.

Enroll in Classes

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

School

Grade Level*

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Registration Fee is $35 and will be charged at time of registration and billed to credit card on file. Children's Academy class fees are $60 per month for a hour class once a week or $72 per month for an hour and a half class once a week. All Adult Classes purchase class card from Becky's during office hours.

Enroll in Classes

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

School

Grade Level*

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Registration Fee is $35 and will be charged at time of registration and billed to credit card on file. Children's Academy class fees are $60 per month for a hour class once a week or $72 per month for an hour and a half class once a week. All Adult Classes purchase class card from Becky's during office hours.

Enroll in Classes

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

School

Grade Level*

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Registration Fee is $35 and will be charged at time of registration and billed to credit card on file. Children's Academy class fees are $60 per month for a hour class once a week or $72 per month for an hour and a half class once a week. All Adult Classes purchase class card from Becky's during office hours.

Enroll in Classes

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

School

Grade Level*

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Registration Fee is $35 and will be charged at time of registration and billed to credit card on file. Children's Academy class fees are $60 per month for a hour class once a week or $72 per month for an hour and a half class once a week. All Adult Classes purchase class card from Becky's during office hours.

Enroll in Classes

Add Another Student

Required Policies and Agreements

Registration Fee $35

All students are required to pay a registration fee when enrolling for future classes. The registration fee will be automatically posted to your account. After you have enrolled for the class, your card will be charged. No refunds.

I've read the above and agree.

Tuition Information

Tuition is due by the first of each month and will automatically be billed to credit card on file. If accounts are paid after the tenth of the month, there will be a $10.00 late fee applied to the account balance. There is a $35.00 returned check charge for any checks returned by the bank. Upon registration your credit card will be charged for 1st month/session/intensive.

I've read the above and agree.

Recital Costume Fees

September 1st $100 Costume Deposit
November 1st Costume Balance (to be determined by instructor costume choice)
No Costume for "Technique Only Classes"

I've read the above and agree.

Recital Fee

April 1st $100 Recital Fee
This fee pays for the recital expenses including renting the facility, custodial and security. This fee will include 2 tickets per dancer.
No Recital Fee for "Technique Only Classes"
Creative Movement Classes Recital Fee - $35 This fee includes an in studio recital, trophy, a flower and a special stuffed animal.

I've read the above and agree.

Release of Liability

As the legal parent or guardian, I release and hold harmless Becky's Academy of Dance, Inc., its owners, instructors, 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 Becky's Academy of Dance, Inc., its owners, instructors, and operators or in route to or from any of said premises.

I've read the above and agree.

Signature Text

As the legal parent or guardian, I release and hold harmless Becky's Academy of Dance, Inc., its owners, instructors, 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 Becky's Academy of Dance, Inc., its owners, instructors, and operators or in route to or from any of said premises.

I've read the above and agree.

Medical Emergency

The undersigned gives permission to , Becky's Academy of Dance, Inc., it's owners, instructors, 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.

Photo Release

As the legal parent or guardian, I give Becky's Academy of Dance and Artistry in Motion the absolute right and permission to use my child's photograph in its promotional materials and publicity efforts. I understand that the photograph(s) may be used in a publication, print ad, direct-mail piece, electronic media (e.g. video, CD-ROM, Internet, World Wide Web), or other form of promotion. I release Becky's Academy of Dance and Artistry in Motion, the photographer, their offices, employees, agents and designees from liability for any violation of any personal or proprietary right I may have in connection with such use. Additionally, I will make no monetary or other claim against Becky's Academy of Dance or Artistry in Motion for the use of the photograph(s)/video.

I've read the above and agree.

Termination of Enrollment

I understand that if I wish to terminate a class that I must give a 30 day written notice. I understand that I will be required to pay for the 30 days. I understand that I will be responsible for paying full tuition until I give my 30 day notice.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Account Information

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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*