Huntington Academy of Dance Online Registration

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Welcome to Huntington Academy of Dance! We are pleased you have chosen us for your dance classes and we welcome you to the studio! If you have questions or need assistance with registration or more information about classes, please call our friendly office staff at (714) 847-6657 or email Info@HuntingtonAcademyofDance.com To register with us, please complete the information below and click submit. Your credit card will not be charged at this time. Happy Dancing!

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Referral Information

How did you hear about us?*

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

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

Student #1

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

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Enroll in Classes

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Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

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Enroll in Classes

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Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

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Enroll in Classes

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Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

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Enroll in Classes

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Required Policies and Agreements

Payment Information

Upon submission of this class and/or event registration my credit card will be charged for the full amount of class(es) and/or event for which I am registering.

I've read the above and agree.

Tuition Information

Tuition is due by the first of each month. Invoices will NOT be sent unless the account is delinquent. 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 $25.00 returned check charge for any checks returned by the bank.

I've read the above and agree.

MEDICAL AND LIABILITY RELEASE

In the event that I, the people listed above or the physician cannot be reached in an emergency, I hereby give permission to the physician selected by Huntington Academy of Dance to give medical treatment for the Participant named above. I understand that first aid may be given to the Participant by affiliated staff, volunteers or other personnel if deemed necessary. Furthermore, I agree to assume full financial responsibility for treatment of any kind. I allow the Participant to participate at HIS/HER OWN RISK and agree to RELEASE, WAIVE, DISCHARGE, and COVENANT NOT TO SUE and agree to HOLD HARMLESS Huntington Academy of Dance, its faculty, staff, independent contractors or volunteers from and against any and all liabilities, demands and claims for injuries, illness, death or property damage which may occur in connection with participation hereto on or near Huntington Academy of Dance, any theater or other related places. I HAVE READ THIS RELEASE, WAIVER OF LEGAL RIGHTS AND ASSUMPTION OF RISK AND FULLY UNDERSTAND ITS CONTENTS. I SIGN IT OF MY OWN FREE WILL.

I've read the above and agree.

I Agree to All of the Above

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Credit Card

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Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

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Zip*