Premiere Dance Center Online Registration

Registration

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Welcome to Online Registration ~ Premiere Dance Center

* 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 # * 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

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*

School*

Grade Level*

Disabilities (Leave blank if NONE)

Allergies*

Medications*

Primary Doctor

* Online registration does secure your spot for classes. If you decide to change classes or withdraw your registration, please notify the studio. * If you have any questions, please call the studio at (765) 284-4488

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*

Disabilities (Leave blank if NONE)

Allergies*

Medications*

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*

School*

Grade Level*

Disabilities (Leave blank if NONE)

Allergies*

Medications*

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*

School*

Grade Level*

Disabilities (Leave blank if NONE)

Allergies*

Medications*

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*

School*

Grade Level*

Disabilities (Leave blank if NONE)

Allergies*

Medications*

Primary Doctor

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 Premiere Dance Center, 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 Premiere Dance Center, 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 Premiere Dance Center, 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 tenth of each month. If accounts are paid after the tenth of the month, there will be a $5.00 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