Ballet with Cindee Velle Online Registration

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Referral Information

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Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Cell # *

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Portal Access (your email is your login)

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Portal Account Password

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Contact #2

Contact #2 First Name

Last Name

Type

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Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Ballet with Cindee Velle. Standard message and data rates apply. Reply STOP to opt out

Email (Emails are kept confidential)

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Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

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Birth Date*

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Student Email

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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

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Student #2 (Show-Hide Details)

Additional Info

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Student #3 (Show-Hide Details)

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Student #4 (Show-Hide Details)

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Student #5 (Show-Hide Details)

Additional Info

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