Expressions Academy of Dance Online Registration

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*

Contact #1

Contact #1 First Name*

Last Name *

How Can We Contact You?

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

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

(format=mm/dd/yyyy)

Additional Info

School

Grade Level

Transportation

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

(format=mm/dd/yyyy)

Additional Info

School

Grade Level

Transportation

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

(format=mm/dd/yyyy)

Additional Info

School

Grade Level

Transportation

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

(format=mm/dd/yyyy)

Additional Info

School

Grade Level

Transportation

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

(format=mm/dd/yyyy)

Additional Info

School

Grade Level

Transportation

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Add Another Student

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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I've read the above and agree.

I Agree to All of the Above

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Questions or Concerns

Comments

Payment Information

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

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number