Richard's School of the Dance Online Registration

Registration

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* 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
(Not Contact #1 or #2)

Health Insurance Carrier

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

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 #

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

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Please select the class genre and level appropriate for the student you are registering. More than one student can be registered at this time, please add students as needed in the form below and select the classes for each. Note: Please do not ask to place your child in the wrong age level or skill level class. Students will be placed according to the discretion of the teaching staff.

Enroll in Classes

Select Another 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

Disabilites

Special Needs

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

Disabilites

Special Needs

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

Disabilites

Special Needs

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

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Enroll in Classes

Select Class *

Add Another Student

Required Policies and Agreements

Payment Policy

There is a $25 per family (non-refundable) registration fee per dance season (Sept - May)
This registration fee GUARANTEES your child's spot in Fall Classes, as well as covering all scheduling, administrative paperwork, computer work, mailing and phone calls PER student, etc.

Payment options: By Month, Term (3 payments), or Full Year

We accept Visa, MasterCard, & Discover, Cash, and Checks

Monthly payments will only be accepted if an automatic payment is set-up through a credit card, or debit card account. Term Past due accounts are any lessons not paid for by September 13th, November 29th, and February 28th.

Note: There will be a $25.00 Late Fee for any payments past due. (This will be strictly enforced.)

Failure to pay account in full will result in removal from class instruction and result in a students in-ability to participate in picture weekend and perform in the annual recital.

I've read the above and agree.

Photo/Video & Liability Wavier

I grant Richard's School of the Dance, it's representatives and employees the right to take photographs/videos of my child in connection with activities within the dance studio, recital, and performances. I authorize Richard's School of the Dance, it's assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Richard's School of the Dance may use such photographs/videos of my child with or without my name and for any lawful purpose, including for examples such purposes as publicity, illustration, advertising, and web content.

1. Waiver of Liability: The undersigned hereby waives any and all claims for personal injury the undersigned, or the minor child on behalf of whom the undersigned is executing this agreement, might otherwise have against Tricia M. Bayer and Richard's School of the Dance (including its teachers, volunteers, sponsors and insurers), arising out of or in any related to such child's participation in dance class sessions, dance recitals, dance practices, dance rehearsals, and other performances.

2. Execution on behalf of a minor child: The undersigned acknowledges and agrees that he/she is executing this agreement on behalf of a child under 18 years of age if applicable listed in the registration form below. The electronic signatures on the following statements are binding and represent full cooperation with the policies and waivers as enforced by Richards School of the Dance.

I've read the above and agree.

Parent/Student Handbook

By filling out this form online you agree to all payment, picture, and studio policies set forth in the studio's Parent/Student Handbook &/or Aerial Arts Handbook

I've read the above and agree.

Electronic Signature

Electronic signatures on the following statements are binding and represent full cooperation with the policies and waivers as enforced by Richards School of the Dance.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

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