Dance motion Online Registration

Registration

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Thank you for choosing Dance Motion!

* 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

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

You will need to order dress code items at www.shopnimbly.com

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

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

You will need to order dress code items at www.shopnimbly.com

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)

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

You will need to order dress code items at www.shopnimbly.com

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)

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

You will need to order dress code items at www.shopnimbly.com

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)

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

You will need to order dress code items at www.shopnimbly.com

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Assumption of Risk

I __________________(Print you name) have to chosen my child_________________(Print Child's name), to participate in dance instruction given my Dance Motion. I acknowledge that I understand the nature of the activities my child will be participating in and that my child is in proper physical condition and capable of participating in the related activities, understanding that Dance Motion is not in any way responsible for making such a determination. In consideration of my child's enrollment in any dance instruction program. I understand and agree on behalf of myself and my child, to release, hold,harmless, and discharge Dance Motion from all claims, costs,liabilities,expenses or judgments,including attorneys' fees and court costs for any occurrences in connection with any dance instruction.

I've read the above and agree.

Release of Liability

I assume all risks to my child in connection with any instruction and further release Dance Motion and its owner and employees from liability for any injury sustained by my child while he or she is enrolled in any dance instruction program, including all risks reasonably connected with such activity whether forseen or unforeseen. I understand that Dance Motion is not responsible for my child or other children under my supervision who are left unsupervised in the common areas and areas surrounding the dance studio and that Dance Motion will only be supervising my child when he or she is participating in scheduled dance activities,programs or instruction. I understand that Dance Motion is not responsible for personal property that is lost,damaged or stolen while I or my child is at or on Dance Motion property. I acknowledge and agree that it is my responsibility to maintain my own accident and health insurance coverage that provides adequate coverage for me and my child participating in Dance Motion activities and that Dance Motion does not provide accident or health insurance for those participating in its instruction, activities or programs.

I've read the above and agree.

Release of Photography

I authorize and agree that Dance Motion may take and use photographs,videos, or likenesses of me or m child as needed for its record-keeping,advertising, and/or public relations projects including Facebook,Instagram, and Twitter and that I have no rights to the same and will not be compensated for the same.

I've read the above and agree.

Payment Policies

I understand my payment is due is due by the 1st of each month for monthly classes and will be considered late by the 5th of each month. A late fee of 10% will be assessed.

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*