Brooke Bailey Dance Addiction Online Registration

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WELCOME! Please fill out the information below. and click submit when complete. Credit Card or Bank accounts are not charged at this time. Registration Fee is $45 per family and will be charged once we review registration. We look forward to having you in our classes!

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Referral Information

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Referral Name*

Family Information

Family Last Name*

Where do you live?

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 # *

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Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 First Name

Last Name

Type

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Home Phone

Work #

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Brooke Bailey Dance Addiction. Standard message and data rates apply. Reply STOP to opt out

Email (Emails are kept confidential)

Confirm Email

Who is your employer?

Employer

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Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

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

Choose any filter to begin viewing classes available. Please note the location of the class you are enrolling in.:Cadiz Location or Main (Hopkinsville).

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

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

Choose any filter to begin viewing classes available. Please note the location of the class you are enrolling in.:Cadiz Location or Main (Hopkinsville).

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

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

Choose any filter to begin viewing classes available. Please note the location of the class you are enrolling in.:Cadiz Location or Main (Hopkinsville).

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

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

Choose any filter to begin viewing classes available. Please note the location of the class you are enrolling in.:Cadiz Location or Main (Hopkinsville).

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

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

Choose any filter to begin viewing classes available. Please note the location of the class you are enrolling in.:Cadiz Location or Main (Hopkinsville).

Enroll in Classes

Select Class *

Add Another Student

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Exp Month *

Exp Year *

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Address Line 1

Address Line 2

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State

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

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

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Student #3 (Show-Hide Details)

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Questions or Concerns

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Required Policies

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