Excel Dance Centre Online Registration

Registration

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Sorry, but this class is no longer available.

Please submit the registration/signed policy form and fees to the studio to reserve your spot.

* 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

Health Insurance Carrier

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

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 # Receive Text Message Notifications

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

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Our students learn about movement, technique and self-confidence through quality instruction by teachers who have a rich dance background and regularly attend various local and regional dance conventions and workshops. Please see our website for proper dance attire requirements.

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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

School

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

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

School

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

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

School

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

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

School

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Release of Liability

I give my permission for my child to be photographed, videotaped, or recorded during events, classes, or performances for use in publications, media, and advertising. I have read and understand the policies regarding payment of classes and costumes, late charges, returned checks, discounts, class drop forms, class cancellations, proper dance attire and shoes, and classroom behaviors. I will not hold Excel Dance Centre or its employees liable for injury or lost/stolen items. I also understand that if I have a child in multiple classes or more than one child attending dance, there is a possibility that we may be split into more than one recital. We do our best to keep you together but as you can guess, it is very difficult. Ticket discounts will be given to each family affected by a split. Thank you for your understanding!

I've read the above and agree.

Signature Text

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

I've read the above and agree.

Medical Emergency

The undersigned gives permission to Excel Dance Centre, 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

Payments are due by the 3rd of each month. Payment choices are check, credit card, cash, or ACH debit. A $5 late fee will be added to your account if not paid by the 3rd. An additional $5 late fee will be charged for each week following that the balance is not paid. Tuition is paid each month (September-June) unless a Drop Form is signed. Tuition is the same whether the month has 3, 4, or 5 weeks. They even out towards the end of the year. Please remember tuition does not change due to absence or studio closing for holidays or inclement weather. You may make up any missed class by calling the studio. A $35 fee will be incurred for any returned checks. Tuition must be paid in full in order to receive costumes.

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 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