5678 Dance Studio Inc Online Registration

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5678 Dance Studio is celebrating its 29th year in business!!! Tuition will be automatically charged on August 1st for our 2022-2023 Season. This payment will hold your child's spot in the class. If payment is not made on or before your child's 1st class your child will be dropped from that class.

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Referral Information

How did you hear about us?*

Referral Name*

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State *

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

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?

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)

Additional Info

Student Email

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)*

Please note that the credit card you submitted during registration is not automatically charged until the 1st of each month.

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

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)*

Please note that the credit card you submitted during registration is not automatically charged until the 1st of each month.

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

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)*

Please note that the credit card you submitted during registration is not automatically charged until the 1st of each month.

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

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)*

Please note that the credit card you submitted during registration is not automatically charged until the 1st of each month.

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

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)*

Please note that the credit card you submitted during registration is not automatically charged until the 1st of each month.

Enroll in Classes

Select Class

Add Another Student

Required Policies

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Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule*

Membership Type*

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*

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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

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

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Questions or Concerns

Payment Information

Account Information

Credit Card

Required Policies

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