Dancers Pointe Howell Online Registration

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Dancers Pointe Howell 2426 Route 9 South Howell NJ 07731 www.DancersPointe.com (732) 534-0012

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Referral Information

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Family Information

Family Last Name*

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Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)*

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Contact #1

Contact #1 First Name*

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Type*

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Home Phone *

Work #

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Contact #2

Contact #2 First Name

Last Name

Type

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Home Phone

Work #

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Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

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Allergies (Leave blank if NONE)

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Has Special Needs? Y/N:*

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Has Special Needs? Y/N:*

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

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Allergies (Leave blank if NONE)

Has Special Needs? Y/N:*

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Has Special Needs? Y/N:*

Enroll in Classes

Select Class *

Add Another Student

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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*

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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

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

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Student #3 (Show-Hide Details)

Additional Info

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Student #4 (Show-Hide Details)

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Additional Info

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