Elite Dance Academy, Inc. Online Registration

Registration

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Please fill out the following registration form and click Submit.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name*

Family Information

Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional 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

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Please select classes. If full, you may choose to go on the 'waitlist'.

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

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Please select classes. If full, you may choose to go on the 'waitlist'.

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

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Please select classes. If full, you may choose to go on the 'waitlist'.

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

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Please select classes. If full, you may choose to go on the 'waitlist'.

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

School

Grade Level

Disabilites

Allergies

Medications

Primary Doctor

Please select classes. If full, you may choose to go on the 'waitlist'.

Enroll in Classes

Select Class *

Add Another Student

Required Policies and Agreements

Release of Liability

As the legal parent or guardian, I agree to release Elite Dance Academy, Inc., it's staff, instructors, or landlords of any liability related to injury to myself or child related to participation in Elite Dance Academy, Inc. classes, rehearsals, performances, or related programs and events.

I've read the above and agree.

Payment Information

I agree to pay, in full, the non-refundable and non-transferable tuition for the registered classes and production costumes as well as an annual registration fee. I understand Elite Dance Academy, Inc. is not responsible for lost or stolen items. I understand monthly tuition is due by the 5th of each month and that tuition will be due monthly until and unless a 30-day advance written notice of withdrawal signed by the parent/guardian is received by the studio (with the exception of contract students). A $15 late fee will be applied to delinquent accounts. Tuition is based on a full season and is not pro-rated for months with holidays or for missed classes. If a make-up class is requested within 2 weeks of the absence, our office will assist in finding a make-up class if there is availability.

I've read the above and agree.

Release II

Photos and videos taken during class, rehearsals, and performances may be used by Elite Dance Academy, Inc. for publicity or marketing materials. Video taping of classes/productions by anyone other than staff is not permissable without express consent of Director.

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

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*