Registration
Welcome to Fusion Dance Center Online Registration!
*
denotes required fields
Referral Information
How did you hear about us?
Current Student
Newspaper Ad
Other
Performance
Referral- Friend
Walk-in / Drive by
Web search
Website
Referral Name
Family Information
Family Last Name
*
Where do you live?
Home Address
*
City
*
State
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NE
NC
ND
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
VI
Zip
*
Primary Phone
*
Additional Info
Emergency Contact Info
Health Insurance Carrier
Enter Coupon Code
Contact #1
Contact #1 First Name
*
Last Name
*
Type
*
Father
Grandparent
Guardian
Mother
Other
Parent
Participant
Step- Parent
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
Contact #2
Contact #2 First Name
Last Name
Type
Father
Grandparent
Guardian
Mother
Other
Parent
Participant
Step- Parent
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
*
Female
Male
Birth Date
*
Cell #
Additional Info
Student Email
T-Shirt Size
Adult Large
Adult Medium
Adult Small
Adult X-Large
Adult X-Small
Adult XX-Large
Child Large
Child Medium
Child Small
Child X-Large
Child X-Small
School
Grade Level
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Primary Doctor
Years of dance Instruction:
Student #2
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
*
Female
Male
Birth Date
*
Cell #
Additional Info
Student Email
T-Shirt Size
Adult Large
Adult Medium
Adult Small
Adult X-Large
Adult X-Small
Adult XX-Large
Child Large
Child Medium
Child Small
Child X-Large
Child X-Small
School
Grade Level
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Primary Doctor
Years of dance Instruction:
Student #3
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
*
Female
Male
Birth Date
*
Cell #
Additional Info
Student Email
T-Shirt Size
Adult Large
Adult Medium
Adult Small
Adult X-Large
Adult X-Small
Adult XX-Large
Child Large
Child Medium
Child Small
Child X-Large
Child X-Small
School
Grade Level
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Primary Doctor
Years of dance Instruction:
Student #4
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
*
Female
Male
Birth Date
*
Cell #
Additional Info
Student Email
T-Shirt Size
Adult Large
Adult Medium
Adult Small
Adult X-Large
Adult X-Small
Adult XX-Large
Child Large
Child Medium
Child Small
Child X-Large
Child X-Small
School
Grade Level
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Primary Doctor
Years of dance Instruction:
Student #5
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
*
Female
Male
Birth Date
*
Cell #
Additional Info
Student Email
T-Shirt Size
Adult Large
Adult Medium
Adult Small
Adult X-Large
Adult X-Small
Adult XX-Large
Child Large
Child Medium
Child Small
Child X-Large
Child X-Small
School
Grade Level
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Primary Doctor
Years of dance Instruction:
Add Another Student
Required Policies
(Show-Hide Details)
I Agree to All of the Above
Enter your Full Name
*
July 1, 2025
Questions or Concerns
Comments
Payment Information
Credit Card
Card Number
*
Visa
Mastercard
Discover
Exp Month
*
01
02
03
04
05
06
07
08
09
10
11
12
Exp Year
*
Card Nickname
Name as it appears on card
*
Address Line 1
Address Line 2
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
VI
Zip
*
Jackrabbit Technologies' class management platform & registration portal is trusted by 1000s of
dance studios
,
gyms
,
swim schools
,
music schools
,
cheer gyms
,
childcare centers
, and
more
.
