Barefoot Dance Studio Online Registration

Registration

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Welcome to Barefoot Dance Studios! Please fill out this form to begin registering for dance classes! Note: You will be charged your Annual Registration Fee $15 (Family Fee $20) after registration. This is NOT charged for Summer classes or camps. If you are a previous student, please log-in above. If you do not know your log-in information, please contact us at barefootdancestudio@gmail.com

* 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

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # Receive Text Message Notifications

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 # Receive Text Message Notifications

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email*

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

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

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

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

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

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

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

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

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Release of Liability

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

I've read the above and agree.

Policies

I acknowledge that I have read and agree to the policies of Barefoot Dance Studio.

I've read the above and agree.

Medical Emergency

The undersigned gives permission to Barefoot Dance Studio, its owners and operators to seek emergency 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've read the above and agree.

Payment Information

Tuition is due by the fifth of each month. If accounts are paid after the tenth of the month, the first late fee of $5.00 will be 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.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule

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