Genia Johnson Dance Company Online Registration

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* PLEASE NOTE * Multi-class discounts and monthly payments are calculated manually. Your card will not be immediately processed at registration. Please allow 48 business hours to process your registration payment.

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Referral Information

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Family Information

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Home Address*

City*

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Zip*

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Additional Info

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

Health Insurance Carrier

Contact #1

Contact #1 First Name*

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Type*

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Work #

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Confirm Email*

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Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 First Name*

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Type*

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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*

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

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Medications (Leave blank if NONE)

Primary Doctor*

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Student's First Name*

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Transportation

Disabilities (Leave blank if NONE)

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Medications (Leave blank if NONE)

Primary Doctor*

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Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

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Student Gender*

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Student Email

T-Shirt Size

School*

Grade Level*

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

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Medications (Leave blank if NONE)

Primary Doctor*

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Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Enroll in Classes

Select Class *

Add Another Student

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e-Payment Schedule*

Membership Type*

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)

Who is your employer?

Contact #2

How can we contact you?

Who is your employer?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

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Student #4 (Show-Hide Details)

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Student #5 (Show-Hide Details)

Additional Info

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