Mary Alice's Dance Studio Online Registration

Registration

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Welcome to Mary Alice's Dance Studio Online Registration! Please feel free to browse our class listings and email us with any questions. Competition classes are not listed below. However, if you would like information about our competition team or company, please contact us at maryalicesdancestudio@gmail.com or 716 662 1080

* 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 #

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

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*

Disabilites

Allergies*

Medications

These classes are open to any student wishing to register at Mary Alice's Dance Studio.

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*

Disabilites

Allergies*

Medications

These classes are open to any student wishing to register at Mary Alice's Dance Studio.

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*

Disabilites

Allergies*

Medications

These classes are open to any student wishing to register at Mary Alice's Dance Studio.

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*

Disabilites

Allergies*

Medications

These classes are open to any student wishing to register at Mary Alice's Dance Studio.

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*

Disabilites

Allergies*

Medications

These classes are open to any student wishing to register at Mary Alice's Dance Studio.

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 Mary Alice's 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, 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 Mary Alice's Dance Studio, its owners and operators or in route to or from any of said premises.

I've read the above and agree.

Signature Text

I've read the above and agree.

Medical Emergency

The undersigned gives permission to Mary Alice's Dance Studio, 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, restrictions, or condition and/or declare the participant to be in good physical and mental health.

I've read the above and agree.

Payment Information

Tuition is due by the first of each month. 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.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Please fill out ONE of the following Payment Methods

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