Expressions Academy of Dance Online Registration

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Referral Information

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Referral Name*

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Contact #1

Contact #1 First Name*

Last Name *

How Can We Contact You?

Work #

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Portal Access (your email is your login)

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Portal Account Password

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Student #1

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

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Primary Doctor

Student #2 (Show-Hide Details)

Student's First Name*

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Student Gender*

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

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Primary Doctor

Student #3 (Show-Hide Details)

Student's First Name*

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Additional Info

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Primary Doctor

Student #4 (Show-Hide Details)

Student's First Name*

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Additional Info

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Primary Doctor

Student #5 (Show-Hide Details)

Student's First Name*

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Student Gender*

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

Additional Info

T-Shirt Size

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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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Required Policies and Agreements

Agerement

Dance is a physical activity that requires the body to be warmed up in order to execute movement safely. Late students miss the proper warm-up and/or barre and therefore may sustain injury. Students who arrive more then 15 minutes late may be asked to observe class for reasons of personal safety.

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