Kerri's Dance Studio Online Registration

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Kerri's Dance Studio 2025-2026

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Referral Information

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Referral Name

Family Information

Family Last Name*

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Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Contact #1

Parent First Name*

Last Name *

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Home Phone *

Work #

Cell #

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

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Contact #2

Contact #2 First Name

Last Name

Type

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Home Phone

Work #

Cell #

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Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

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Preferred Name:

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Special Needs (Leave blank if NONE)

Preferred Name:

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Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Special Needs (Leave blank if NONE)

Preferred Name:

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Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

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Preferred Name:

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Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

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Comments

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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

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

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Student #5 (Show-Hide Details)

Additional Info

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