Alta Loma Dance Academy Online Registration

Registration

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Please fill out the following information to complete online class registration.

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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 # Receive Text Message Notifications

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell # Receive Text Message Notifications

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor*

Years prior dance experience*

Location of prior experience

T-shirt size

Please use the schedule search function to select the class(es) that you wish to register for. If you are unsure of which class is the best fit for you, let us know in the comment box at the bottom of the form and we would be more than happy to assist you!

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor*

Years prior dance experience*

Location of prior experience

T-shirt size

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

T-Shirt Size

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor*

Years prior dance experience*

Location of prior experience

T-shirt size

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

T-Shirt Size

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor*

Years prior dance experience*

Location of prior experience

T-shirt size

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

T-Shirt Size

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor*

Years prior dance experience*

Location of prior experience

T-shirt size

Enroll in Classes

Select Class

Add Another Student

Required Policies

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Questions or Concerns

Comments

Payment Information

Please fill out ONE of the following Payment Methods

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Card Number

Exp Month

Exp Year

Card Nickname

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Address Line 1

Address Line 2

City

State

Zip

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number

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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

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Student #2 (Show-Hide Details)

Additional Info

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Student #3 (Show-Hide Details)

Additional Info

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Additional Info

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Questions or Concerns

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Required Policies

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