Holly Rochelle Dance Company Online Registration

Registration

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All accounts require a credit card on file. However, no charges will be made until student enrolls in a class. We look forward to seeing your student in class. Please let us know if you have any questions. HRDC

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Referral Information

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Referral Name

Family Information

Family Last Name*

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Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info

Contact #1

Contact #1 First Name*

Last Name *

Type*

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Home Phone

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Cell # *

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Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

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Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

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Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

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Medications (Leave blank if NONE)

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Student #4 (Show-Hide Details)

Student's First Name*

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Student Gender*

Birth Date*

Additional Info

Student Email

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Special Needs (Leave blank if NONE)

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Medications (Leave blank if NONE)

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Enroll in Classes

Select Class

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Required Policies

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Comments

Payment Information

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)

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Student #5 (Show-Hide Details)

Additional Info

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Credit Card

Required Policies

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