Brooke Bailey Dance Addiction Online Registration

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!

* 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*

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

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 #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

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* (format=mm/dd/yyyy)

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* (format=mm/dd/yyyy)

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* (format=mm/dd/yyyy)

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

Required Policies and Agreements

Payment Information

Tuition is due by the first of each month. If tuition has not been paid by cash or check by the 6th we will charge the amount owed from your bank account or credit card on file.

I've read the above and agree.

Medical Emergency

The undersigned gives permission to Brooke Bailey Dance Addiction, 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, 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.

Cancellation Policy

To cancel your enrollment from a dance or gymnastics class please submit an email or letter. Please allow 30 days for un enrollment to take place.

I've read the above and agree.

Release of Liability

As the legal parent or guardian, I release and hold harmless Brooke Bailey Dance Addiction, 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 Brooke Bailey Dance Addiction, its owners and operators or in route to or from any of said premises.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Please fill out CREDIT CARD Payment Method

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*

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number