The Movement Dance Academy Online Registration

The Movement Dance Academy

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Referral Information

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Parent Information

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Where do you live?

Home Address*

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Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

Contact #1

Contact #1 First Name*

Last Name *

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How Can We Contact You?

Home Phone *

Work #

Cell #

Portal Access (your email is your login)

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Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

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Work #

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Confirm Email

Student #1

Student's First Name*

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Student Gender*

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Additional Info

Student Email

T-Shirt Size

School*

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Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Student #2 (Show-Hide Details)

Student's First Name*

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Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School*

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Disabilities (Leave blank if NONE)

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Medications (Leave blank if NONE)

Student #3 (Show-Hide Details)

Student's First Name*

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Student Gender*

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Additional Info

Student Email

T-Shirt Size

School*

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Disabilities (Leave blank if NONE)

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Medications (Leave blank if NONE)

Student #4 (Show-Hide Details)

Student's First Name*

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Student Email

T-Shirt Size

School*

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Disabilities (Leave blank if NONE)

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Medications (Leave blank if NONE)

Student #5 (Show-Hide Details)

Student's First Name*

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Additional Info

Student Email

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School*

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Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

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Comments

Payment Information

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Account Number *

Registration

Referral Information

Parent 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

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

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I Agree to All of the Above

Questions or Concerns

Payment Information

eCheck/Bank Draft

Required Policies

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