Academy of Dance Online Registration

Registration

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Welcome to the Academy of Dance! Please provide your information and click SUBMIT when complete. All enrollments are considered pending until we have reviewed your registration and posted any fees due. Applicable discounts will be applied manually as well. If you have any questions, please call us at 478 922 6220.

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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

Zip*

Primary Phone*

Additional Info

Emergency Contact Info<br/>(Not Mom or Dad)*

Health Insurance Carrier

Military Family

Family Emergency Contact*

Alternate Pickup Person

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # *

Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Academy of Dance. Standard message and data rates apply. Reply STOP to opt out

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. By opting in, you agree to receive SMS messages from Academy of Dance. Standard message and data rates apply. Reply STOP to opt out

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Academy of Dance. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Child's nickname

Recital Y/N

Agree to Photo Release*

Choose any filter to begin viewing available classes.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Academy of Dance. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Child's nickname

Recital Y/N

Agree to Photo Release*

Choose any filter to begin viewing available classes.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Academy of Dance. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Child's nickname

Recital Y/N

Agree to Photo Release*

Choose any filter to begin viewing available classes.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Academy of Dance. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Child's nickname

Recital Y/N

Agree to Photo Release*

Choose any filter to begin viewing available classes.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Academy of Dance. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Child's nickname

Recital Y/N

Agree to Photo Release*

Choose any filter to begin viewing available classes.

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

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

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)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies

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