Theatre De La DanSe Online Registration

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Theatre De La DanSe

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Referral Information

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Family Information

Last Name*

Where do you live?

Home Address*

City*

State*

Postal Code*

Home or Primary Phone*

Additional Info

Emergency Contact Info - Please list someone other than you and their contact number*

Contact #1

Parent/Guardian 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

Contact #2

First Name*

Last Name*

Type*

How can we contact you?

Home Phone

Work #

Cell # *

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

School*

Year Level at School*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Epipen user - Yes or No?*

Please contact the office info@tdld.com.au if you're not sure which class to select.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

School*

Year Level at School*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Epipen user - Yes or No?*

Please contact the office info@tdld.com.au if you're not sure which class to select.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

School*

Year Level at School*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Epipen user - Yes or No?*

Please contact the office info@tdld.com.au if you're not sure which class to select.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

School*

Year Level at School*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Epipen user - Yes or No?*

Please contact the office info@tdld.com.au if you're not sure which class to select.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

School*

Year Level at School*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Epipen user - Yes or No?*

Please contact the office info@tdld.com.au if you're not sure which class to select.

Enroll in Classes

Select Class

Add Another Student

Required Policies

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Questions or Concerns

Comments

Payment Information

Please fill out ONE of the following Payment Methods

Credit Card

Card Number

Exp Month

Exp Year

Card Nickname

Name as it appears on card

Address Line 1

Address Line 2

City

State

Postal Code

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank State Branch (BSB) Number (6-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)

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

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Student #4 (Show-Hide Details)

Additional Info

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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

eCheck/Bank Draft

Required Policies

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